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Peer Reviewed

Photoclinic

Lemierre Syndrome Caused by MRSA In an Infant

Mathews Roy, MD • Kaili Yang, MD • Amee Patel, MD, MPH

AFFILIATION:
Department of Pediatrics, University of Texas Southwestern, Dallas, Texas

CITATION:
Roy M, Yang K, Patel A. Lemierre syndrome caused by MRSA in an infant. Consultant. 2023;63(4):e7. doi:10.25270/con.2022.10.000002

Received April 7, 2022. Accepted April 26, 2022. Published online September 30, 2022.

DISCLOSURES:
The authors report no relevant financial relationships.

DISCLAIMER:

The authors report that informed parental consent was obtained for publication of the images used herein.

CORRESPONDENCE:
Amee Patel, University of Texas Southwestern, 5323 Harry Hines Blvd Dallas, TX 75390 (amee.patel@utsouthwestern.edu)


Abstract

Lemierre syndrome is a rare disease that results in bacteremia, internal jugular vein thrombophlebitis, and septic emboli. Classically defined as an infection of the posterior compartment of the lateral pharyngeal space by Fusobacterium necrophorum affecting adolescents and young adults, there is considerable morbidity and mortality if appropriate antibiotics are not initiated. Despite becoming a “forgotten disease'' after the introduction of antibiotics, there has been a recent resurgence of cases within the last 20 years. Therefore, it is crucial that clinicians are educated on the clinical features of this rare yet serious condition so that they can appropriately diagnose and treat it in a timely fashion. We describe a case of a 9-month-old infant who presented with acute onset right neck and chest swelling ultimately found to have methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and a right internal jugular vein thrombus consistent with Lemierre syndrome. Our case highlights an evolving diversity of aerobic organisms involved with the syndrome, concerning trends of increasing rates in younger pediatric populations, the therapeutic role of surgical intervention in addition to antibiotics, and the utility of long-term anticoagulation in the setting of lacking evidence.

Key words: Lemierre syndrome, pediatrics, thrombophlebitis, MRSA, antibiotics, anticoagulation

 

Case Presentation

A 9-month-old girl presented to our emergency room with an atraumatic right-sided neck mass that was tender to palpation. She was otherwise healthy when the initial symptoms of low-grade fevers and erythematous nonpruritic skin changes began 1 week prior, for which she was evaluated in the emergency department (ED) and given antipyretics and hydrocortisone cream. Her parent was instructed on supportive care measures. Over the next few days, however, she developed hardened nodules on her lateral neck, decreased neck movement secondary to pain, progressively higher fevers, irritability, drooling, and decreased oral intake. 

Initial vital signs showed the following: temperature of 37.8°C, heart rate of 163 beats/min, respiratory rate of 34 breaths/min, and blood pressure of 90/53 mm Hg. In the ED, the infant was started on intravenous clindamycin and fluids. Laboratory testing showed elevated inflammatory markers, and hypoalbuminemia. An ultrasound of the swollen area of the neck demonstrated nonspecific soft tissue swelling. A complete blood count showed a slight neutrophil predominance and bandemia. Urine culture and blood culture were collected. 

However, upon admission to the pediatric hospital medicine floor, evaluation showed an acute clinical change within 12 hours. The patient had an overall toxic appearance with fussiness, nuchal rigidity, and extensive right neck and clavicular swelling. She was also noted to have a 3- by 4-inch indurated nodule in the right cervical region without overlying erythema and 2 small satellite modules measuring 1 cm in the posterior chain. These findings, coupled with early growth of gram-positive cocci in pairs and clusters on blood cultures, led to expanding empiric coverage with intravenous vancomycin and ceftriaxone. Computed tomography of the neck showed extensive right neck edema extending into the supraclavicular region and anterior chest and a focal filling defect in the right proximal internal jugular vein (Figure 1). Guidance from infectious disease and hematology teams was requested. Anticoagulation with enoxaparin sodium was initiated due to an intramural thrombus, with a goal anti-Xa level of 0.5 to 1 unit/mL. Once blood cultures resulted in methicillin-resistant Staphylococcus aureus (MRSA), ceftriaxone was discontinued.

Figure 1. Computed tomography of the neck with contrast in sagittal view. The arrow points to the filling defect in the right internal jugular vein.

Approximately 48 hours into initiating antibiotics, the patient’s fever curve, inflammatory markers, duration between blood culture MRSA positivity, and clinical examination improved. However, on day 7, clinical status worsened with decreased oral intake, irritability, tachycardia, and recurrent fevers. Physical examination findings at this time demonstrated an overall improvement in edema, however, a focal fluctuant mass had overtaken the originally indurated nodule. These findings, in combination with persistent MRSA blood cultures, led us to pursue further imaging with magnetic resonance imaging of the neck to evaluate for an abscess as a source for continual nidus of bacteremia. Results showed phlegmonous changes within the right lower cervical soft tissues, early abscess formation in the subcutaneous fat overlying the right pectoralis muscle measuring 1.5 × 2.9 cm, and interval resolution of right internal jugular vein thrombus (Figure 2). Additional evaluation for septic emboli was done with a liver ultrasound, which was within normal limits. 

Figure 2. Magnetic resonance venography of the neck with contrast in coronal view. This image demonstrates interval resolution of the right internal jugular vein filling defect.

On day 10, the patient was taken for incision and drainage of her chest wall abscess under sedation. Approximately 5 cc of purulent discharge was expressed, and wound cultures grew MRSA. She tolerated the procedure well, and a vessiloop drain was put in place for 1 week. The following day her vital signs stabilized, and her constitutional symptoms and swelling resolved. Her subsequent blood cultures no longer had growth. Given the drastic improvement with surgical intervention and culture susceptibility, she was switched to oral clindamycin. Once stable on oral antibiotics for 48 hours, she was cleared for discharge with instruction to follow-up with infectious disease and hematology specialists. No other complications were reported after discharge. The patient’s hospital course and fever curve during her admission is summarized in Figure 3.