A 45-year-old previously well Sri Lankan lady was admitted to the Teaching Hospital, Kandy, Sri Lanka with severe shortness of breath and respiratory distress for a duration of 24 h.
She had experienced sore throat and mild fever 10 days back followed by left-sided neck pain for the last 5 days. Pain was not radiating but aggravated by neck movements. There was no associated trauma to the neck. Subsequently, the patient had noted progressive facial and left upper limb swelling without any color changes and motor or sensory disturbances. For the past 24 h, she had experienced progressive shortness of breath. There was no odynophagia, pleuritic chest pain, cough or hemoptysis. She denied constitutional symptoms, features suggestive of connective tissue disorder and past history of miscarriages or thromboembolic diseases. She had no recent travel history or sexual risk behaviors. Drug and allergic history were nil of note.
On examination, she was obese with a body mass index (BMI) of 28.4 kg/m2. Her axillary temperature was 100 F. Symmetrical facial swelling and left upper limb swelling were noted but had no color changes in the swollen areas. Ear and throat examinations were unremarkable. There was no cervical lymphadenopathy. Cord sign (an induration of the internal jugular vein beneath the anterior border of the sternocleidomastoid muscle) was positive. Her pulse rate was 130 beats per minute, low volume pulse noted with pulsus paradoxus, blood pressure was 80/50 mmHg, and had soft heart sounds. Respiratory rate was 48 cycles per minute; oxygen saturation was 93% on air and had bi-basal reduced air entry with stony dull percussion note. Abdominal and neurological system examinations were unremarkable.
Urgent investigations revealed sinus tachycardia with electrical alternans in the electrocardiogram and cardiomegaly with bilateral pleural effusions on chest roentgenogram. Echocardiogram showed evidence of pericardial tamponade with right atrial and right ventricular collapse. Pericardial fluid aspiration was performed under sterile conditions, removing 450 ml of straw color fluid. Subsequently, her respiratory distress settled and blood pressure normalized. Further investigations revealed the following: hemoglobin - 11 g/dL, white cell count - 17.7 x 103/muL (neutrophils - 86.2%, lymphocytes - 6.9%, monocytes - 6.1%, eosinophils - 0.7%, basophils - 0.1%), and platelets - 486 x 103/muL. Blood picture was suggestive of bacterial infection (polymophonuclear leucocytes with left shift up to band forms and mild thrombocytosis). Her erythrocyte sedimentation rate was 52 mm in the first hour (normal <20) and C-reactive protein level was 162 units (normal <5 units). Two blood cultures were positive for MRSA species. Pericardial fluid analysis showed the following: protein - 4 g/dL, white cells - 156/muL (neutrophils - 90%, lymphocytes - 9%), acid fast bacilli - not seen, liquid culture for mycobacterium tuberculosis - no growth, adenosine-deaminase level - 35 units/L, cytology - negative for malignant cells. Pericardial fluid culture revealed a growth of MRSA in 26 h of incubation.
Ultrasound scan and venous duplex scan of the neck showed thrombosis of left internal jugular, left external jugular, and left subclavian and left axillary veins with preserved flow in superior vena cava. Computed tomography (CT) scan of the neck and the chest showed similar findings to the venous duplex with additional moderate pericardial effusion (following first pericardiocentesis), bilateral pleural effusion, and left-sided consolidation of the lung (Figure 1). No lymphadenopathy or retropharyngeal abscess formation was noted in CT scan. Abdominal ultrasound scan was normal.
Her urine analysis, lactase dehydrogenase level and renal and liver function tests were normal. Nebulized samples for sputum acid fast bacilli staining and Mantoux test were negative. Serology for infectious mononucleosis, Epstein-barr virus, hepatitis B and C, and human immunodeficiency virus showed negative results. Thrombophilia screening was normal (anti-nuclear antibodies, anti-cardiolipin antibodies, homocysteine level, sickling test and factor V Leiden mutation).
The diagnosis of Lemierre's syndrome secondary to community-acquired MRSA was made with the evidence of history of sore throat, left internal jugular vein thrombosis, MRSA septicemia and distant metastatic infection involving pleura and pericardium, resulting in pleural and pericardial effusions. Pericardiocentesis was performed three times on day 0, day 1, and day 3 due to repeated tamponade effect. Patient was treated initially with intravenous meropenem and subsequently changed over to intravenous vancomycin (according to the antibiotic sensitivity of MRSA) and clindamycin. She showed dramatic response with complete resolution of symptoms and normal follow-up echocardiogram findings. Intravenous antibiotics were continued for 2 weeks and oral clindamycin was continued for further 4 weeks. Patient was initially given intravenous heparin followed by warfarin for a duration of 3 months. On further follow-up after 2 months, patient was completely asymptomatic without residual effects and repeat venous duplex of the neck veins showed recanalization and restoration of the blood flow in the previously thrombosed veins.
Contrast-enhanced CT of chest showing pericardial effusion (white arrow), bilateral pleural effusions and left-sided lung consolidation (red arrow).