We present a 25 year old male who presented to ED with a 4 day history of severe sore throat, mild diffuse abdominal pain and flu-like symptoms of body aches, weakness, and fever. He had originally visited an urgent care center 2 days prior, where Monospot and Rapid Strep tests were negative. He was discharged at that time with azithromycin and prednisone. His symptoms progressively worsened and he also reported new onset nausea, vomiting, diarrhea, dizziness, sweating, chills and 2 episodes of syncope, which prompted this visit to the ED. He denied any recent dental procedures, sick contacts, recent travel, or IV drug use.
His physical exam at that time revealed slightly low but still normotensive blood pressure of 104/60 mmHg, tachycardic heart rate at 133 bpm, respiratory rate 17 bpm, temperature 101.7 F, and oxygen saturation at 93% room air. Significant findings included tonsils with 3+ enlargement, erythematous posterior pharynx with no exudates, dry mucous membranes, and positive lymphadenopathy of anterior and posterior cervical lymph nodes. His chest was clear to auscultation and percussion bilaterally with no tenderness of the chest wall. Exam of his skin did not show any Janeway lesions, Osler nodes or splinter hemorrhages
A complete blood count showed significant leukocytosis with WBC 35,400, hemoglobin 13.5 g/dL, hematocrit 39.9%, and platelets 557,000. He was found to have mild hyponatremia with a sodium of 131 mEq/L but with otherwise normal electrolytes (potassium 5 mEq/L, chloride 95 mEq/L, CO2 25 mEq/L), normal kidney function (BUN 12 mg/dL, creatinine 0.85 mEq/L). Liver function was found to be abnormal with ALT 103 IU/L, AST 48 IU/L, alkaline phosphatase 122 IU/L, total bilirubin 2.0 mg/dL. Initial imaging consisted of a chest x-ray which showed no acute cardiopulmonary process. (Fig. 1) A CT-angiogram of the chest with and without contrast showed multiple cavitary lung masses, suggestive of septic emboli, including a dominant cavitary lung mass at the right base measuring up to 4.4 cm. There was also a trace right pleural effusion. (Fig. 2) Tuberculosis testing was performed as well and found to be negative.
Patient was subsequently admitted under the Infectious Disease service for diagnosis of septic emboli. He was placed on IV piperacillin/tazobactam and IV vancomycin. Echocardiogram showed normal left ventricular ejection fraction at approximately 65 +/- 5%, mildly enlarged right ventricle. No clots, masses or vegetations were visualized. The patient underwent a right video-assisted thoracoscopic surgery with drainage of pleural effusion (400 mL), partial decortication, and right lower lobe wedge excision of right lower lobe lung abscess by cardiothoracic surgery. Lung tissue and pleural fluid cultures were obtained. There was concern for Lemierre's disease so a Doppler of bilateral internal jugular veins was obtained, which was negative for thrombus. Carotid Dopplers were also performed and showed mild stenosis (0-50%) in internal carotid arteries bilaterally and normal vertebral flow bilaterally. On the 5th day of incubation, the culture of the right lower lung tissue grew fusobacterium necrophorum. Blood and pleural fluid cultures returned negative. Lung tissue pathology for the wedge resection showed acute bronchopneumonia with abscess formation, rare blood vessels with organizing thrombus and focal infarction with no evidence for malignancy.
The patient's clinical course continued to improve; WBC count trending down to normal range and his fevers resolved. A PICC line was placed, antibiotics were de-escalated to ceftriaxone and metronidazole and the patient was discharged home. At this time, patient has continued to do well with no recurring symptoms.