Abstract Introduction Lemierre’s syndrome is a rare but life-threatening sequela of oropharyngeal infections, classically caused by Fusobacterium necrophorum that results in local venous thrombosis, septic emboli, and other complications. Diagnosis and management can be complicated by other conditions such as polymicrobial infections, pleural complications, and cardiac involvement. We present a case notable for polymicrobial infection with Fusobacterium necrophorum and Staphylococcus aureus leading to sepsis-associated cardiomyopathy and bilateral loculated parapneumonic effusions requiring interpleural fibrinolysis. Case Report An 18-year-old man presented after five days of sore throat, fever, malaise and new right flank discomfort. He became hypotensive requiring vasopressors and was admitted to the intensive care unit. The CT scan of his chest showed multifocal pulmonary nodules and a wedge-shaped infarct consistent with septic emboli. CT neck revealed right internal jugular thrombosis and peritonsillar abscess. Transthoracic echo showed new systolic dysfunction with an ejection fraction of 28% and global hypokinesis. Blood culture grew Fusobacterium necrophorum. Respiratory culture grew heavy Staphylococcus aureus. Despite appropriate therapy with ampicillin-sulbactam, he developed progressive leukocytosis and respiratory distress. CT chest and bedside ultrasound revealed new bilateral loculated pleural effusions. Bilateral pigtail catheters were placed, and pleural fluid studies showed an exudative process with neutrophilic predominance. No organisms were seen in the pleural cultures. Intrapleural tissue plasminogen activator and dornase were administered for six doses bilaterally, but therapy on the left was discontinued early due to pleural bleeding. Repeat imaging showed interval improvement without need for surgical decortication. Repeat echocardiogram showed normalization of his ejection fraction. The patient was discharged on a four-week antibiotic course with full radiographic and clinical resolution at his one-month follow-up appointment. Discussion This case illustrates the evolving spectrum of Lemierre’s syndrome, highlighting the potential for polymicrobial co-infection, septic pulmonary emboli, pleural complications, and transient heart failure. Although Fusobacterium remains the hallmark pathogen, polymicrobial infection has been estimated in about one-third of cases. The presence of Staphylococcus aureus in this case highlights the importance of multiple cultures to ensure appropriate antibiotic coverage. This case also showed the progression from pulmonary consolidations to loculated pleural effusions that required successful administration of intrapleural fibrinolytics, leading to avoidance of surgical intervention. Lastly, sepsis-induced cardiomyopathy is not commonly reported with Lemierre’s syndrome. Shock and severe systemic inflammation can precipitate transient myocardial disease. Awareness of potential cardiac complications should prompt early echocardiographic assessment. This abstract is funded by: None
Barrios et al. (Fri,) studied this question.