A 27-year-old female presented to the urgent care with 3 days of fever, generalized myalgia, and sore throat. At the urgent care, she did not receive antibiotics and was symptomatically managed. Her sore throat improved in a day but developed neck pain and hematuria that prompted her to visit emergency department (ED) after 2 days. She denied any other symptoms or any significant past medical history.
On general examination, she was alert, oriented to time, place, and person. She was febrile 101 F, stable blood pressure, stable heart rate, and SaO2 of 98% on room air. The patient had nonexudative erythematous pharynx and lateral neck tenderness. On auscultation, a systolic flow at the left upper sternal border and bilateral diffuse crackles in the lungs were heard. Splenomegaly was absent. Neurological examination was intact.
On admission, the laboratory study showed a white cell count of 21.6 x 103 cells/microL with 89.5% neutrophils, positive left shift, platelet of 9 x 103/microL, and hemoglobin of 10.0 g/dL with normal mean corpuscular volume. The reticulocyte count was normal, lactate dehydrogenase (LDH) was 210 U/L, and haptoglobin was 306 mg/dL. A peripheral smear showed normal red blood cell morphology, toxic granulation, and few giant platelets. Renal function showed increased blood urea nitrogen (BUN) 57 mg/dl, increased creatinine 3.43 mg/dl, and decreased eGFR 16 ml/min/1.73 m2 and sodium 131 mEq/l. Urinalysis showed gross hematuria with no RBC cast and negative nitrite/esterase. Arterial blood gas analysis revealed respiratory alkalosis with pH 7.482, pCO2 30, normal bicarbonate, and anion gap.
Infectious workup includes blood culture positive for Fusobacterium nucleatum and negative rapid streptococcal test, throat culture, monospot test. Fecal leukocytes and ova/parasites tests were negative. A fungal workup was negative for histoplasma, blastomycosis, cryptococcus, and tuberculosis.
An initial chest X-ray is shown in Figure 1.
Positive findings on chest CT and MRI venogram are shown in Figures 2 and 3, respectively. CT abdomen/pelvis and transthoracic echocardiography findings were normal.
Venous imaging to see septic thrombophlebitis include upper extremity/neck venous duplex is shown in Figure 4.
Partial thromboplastin time was 26.4 seconds, D-dimer was 1223 ng/ml DDU, and fibrinogen was 752 mg/dL. The anticardiolipin antibody was positive, with an IgM level of 15.7 and low protein C with a level of 51 (normal 74-150%). An autoimmune workup for secondary causes of hypercoagulation was ruled out including lupus, factor-V Leiden mutation, and malignancy.
The patient was initially managed with fluids, broad-spectrum antibiotics such as meropenem and bridging mechanical ventilation in the intensive care unit. After imaging and blood culture were suggestive of Lemierre's syndrome, the patient was immediately started on piperacillin/tazobactam 4.5 gm IV 6 hourly and heparin drip with a goal aPTT of 60-80 seconds. The patient's symptoms significantly improved with this antibiotic regimen and anticoagulation. Heparin was switched to warfarin with a goal INR of 2-3, and piperacillin/tazobactam switched to clindamycin 300 mg q6hr with probiotic for 3 weeks for extended coverage of infection.
During the 2 months of follow-up, the patient had a complete resolution of symptoms, a positive beta-glycoprotein but normal IgM level. The patient was then scheduled for repeat MRI venogram in three months.