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Neuroradiology Case of the Week
Case 428
July 2009
Gurshawn Singh MS2, Rajiv Mangla MD, and P-L Westesson, MD, PhD, DDS
Clinical
Presentation: A 16-year-old female presented with history of sore throat, fever, septicemia, and abnormal chest X-ray.
Imaging Findings: Contrast enhanced axial CT showed complete thrombosis of one of the tributaries of the left internal jugular vein draining the area oropharynx (Fig. 1). There was also partial thrombosis of right internal jugular vein (Figs. 2&3). The apical lung showed bilateral infiltrates.
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Figure 1: Contrast enhanced axial CT showed thrombosis of one of the tributaries of the left internal jugular vein
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| Figure 2: The same tributary is joining the left internal jugular vein. |
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| Figure 3: The lower section shows partial thrombosis of the left internal jugular vein (arrow). |
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| Figure 4: Apical lung shows bilateral infiltrates most likely due to septicemia. |
Diagnosis: Lemierre’s disease
Discussion: Lemierre’s disease is a bacterial infection caused by the anaerobic gram negative rod, Fusobacterium necrophorum. The infection starts out primarily as pharyngitis, hence sore throat and fever with pharyngeal inflammation is common. The bacterium exists in the normal flora of the oropharynx and the infection can be precipitated by different events.
The primary source of the infection is usually the palatine tonsils and peritonsillar tissues. These present as exudative tonsillitis or peritonsillar abscesses. The infection occurs in several stages, first being the pharyngeal infection. The bacterium will invade the deep pharyngeal tissue and drain the lateral pharyngeal space, and is known to cause internal jugular vein septic thrombophlebitis. Following this stage of the disease, there are usually metastatic complications which can arise. The infection may spread to the lungs, spread to joints as septic arthritis, develop soft tissue lesions or abscesses, and cause cardiovascular, renal, and hematological complications.
The most common metastatic complication is the pulmonary involvement, and it can easily be seen on x-ray. These lesions will start early and cause pleuritic pain with dyspnea. The radiograph will show multiple nodular infiltrates in the lung fields and small pleural effusions. Chest radiographs are known to show cavitating pneumonia similar to bacterial endocarditis with septic embolization. In 44% of patients, cavitation was not detected on chest films, but rather seen only on chest CT.
This patient presented with symptoms of a sore throat and fever, with a small mass on their neck. She had evidence of a thrombus in one of the tributaries of the left internal jugular vein. This tributary is coming from the region of the left side of the oropharynx and draining into the internal jugular vein. This thrombus also extends mildly into the left internal jugular vein causing partial thrombosis in its short segment of the left internal jugular vein. Hypoxic lesions were also present on chest radiographs. There are also a few lymph nodes in the upper neck region. These lymph nodes measure up to 2 cm in size indicating possible lymphadenopathy. These findings are consistent with the clinical diagnosis of Lemierre's disease.
References:
- Chirinos JA, Lichtstein DM, Garcia J, Tamariz LJ. The evolution of Lemierre syndrome: report of 2 cases and review of the literature. Medicine (Baltimore). 2002 Nov;81(6):458-65. PMID: 12441902 [PubMed]
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Riordan T, Wilson M. Lemierre's syndrome: more than a historical curiosa. Postgrad Med J. 2004 Jun;80(944):328-34. PMID: 15192164 [PubMed]
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