Transcript Patient TC

Case of T.C.:
Presentation, Evaluation and
Management of
Lemierre’s Syndrome
Patient TC
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16 year old male
CC: anterior chest wall swelling and RLE pain
HPI:
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Questionable history of trauma
Pain of chest wall and with movement of LUE
Development of clinical jaundice
Onset of swelling and pain in RLE
Presentation to OSH 2/9/10
Patient TC
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PMH: None, no prior hospitalization
PSH: None
FH: No sick contacts. Non-contributory.
SH: Lives in Renton with parents, sister.
ROS:
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- : fever, headache, rash
+ : fatigue, congestion, cough, mild dyspnea,
anorexia, nausea, diarrhea, decreased UOP,
jaundice
Patient TC
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PMH: None, no prior hospitalization
PSH: None
FH: No sick contacts. Non-contributory.
SH: Lives in Renton with parents, sister.
ROS:
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- : fever, headache, rash
+ : fatigue, congestion, cough, mild dyspnea,
anorexia, nausea, diarrhea, decreased UOP,
jaundice
Patient TC
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OSH Course:
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Pan CT:
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Empyema on right
Erosion of left sternoclavicular joint
Air/fluid in anterior chest wall
Signs of septic right knee, ? compartment
syndrome
Patient TC
Patient TC
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OSH Course:
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Pan CT:
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Empyema on right
Erosion of left sternoclavicular joint
Air/fluid in anterior chest wall
Signs of septic right knee, ? compartment
syndrome
Urgently transferred to Seattle Children’s
Patient TC
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ED Presentation:
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Per report, enlargement of chest wall swelling enroute
PE:
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BP 117/34, HR 141, RR 24, 96% on RA
Gen: Jaundiced, diaphoretic, ill-appearing
CV: No murmurs/rubs/gallops
Chest: CTAB, no stridor, wheezing
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Left pectoralis indurated with TTP and purulent drainage over
medial clavicle
Abd: Hepatomegaly
Ext: RLE edematous with pain on dorsiflexion
Patient TC
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ED Presentation
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Labs:
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Na 119, K 5.4, Cl 84, CO2 26, BUN 15, Cr 0.5
WBC 12.6 (24 bands), Hct 27,3, Plt 405
INR 1.6
Dbili 7.8, CRP 23.2, ESR 53
Patient TC
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ED Presentation
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Labs:
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Na 119, K 5.4, Cl 84, CO2 26, BUN 15, Cr 0.5
WBC 12.6 (24 bands), Hct 27.3, Plt 405
INR 1.6
Dbili 7.8, CRP 23.2, ESR 53
Taken emergently to the OR
Patient TC
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OR Findings:
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Purulent material with crepitus
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Erosion of sternoclavicular joint
Initial compartment pressures:
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Left anterior chest wall
Deltopectoral groove
Over pectoralis/anterior surface of left shoulder
Anterior - 50
Lateral - 45
Deep posterior - 45
Superficial posterior - 75
Drainage of purulent fluid in right knee
Patient TC
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Hospital Course
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Started empirically on vanc, meropenem, clinda,
gent
Required pressors intra-op and in PICU -- off by
HD 3
Normalized coagulopathy by HD3
Multiple OR trips for debridement
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3 chest tubes placed on right on HD 2
Additional chest tube on left on HD 5
Patient TC
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Hospital Course
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Blood cultures - negative
Wound/Tissue cultures - grew abundant
fusobacterium species
Neck U/S (HD #2):
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Superior to mid IJ completely occluded
Thrombosed with small amount of flow
Inferior portion has collateral flow
Patient TC
Patient TC
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Hospital Course
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Blood cultures - negative
Wound/Tissue cultures - grew abundant
fusobacterium species
Neck U/S (HD #2):
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Superior to mid IJ completely occluded
Inferior portion has collateral flow
Thrombosed with small amount of flow
Wound vac placed 2/17
Drainage of pharyngeal abscess by OTO 2/20
Patient TC
Lemierre’s Syndrome
Lemierre’s Syndrome
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Definition:
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History of oropharyngeal infection
Clinical/radiographic IJ vein thrombosis
Isolation of anaerobic pathogens
Metastatic abscesses
History:
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1900 - Courmont and Cade
1936 - Lemierre
Lemierre’s Syndrome
“The appearance and repetition several days after the onset of
sore throat of severe pyrexial attacks with an initial rigor, or still
more, the occurrence of pulmonary infarcts and arthritic
manifestations, constitute a syndrome so characteristic that
mistake is almost impossible.”
-- Lemierre
Lemierre’s Syndrome
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Epidemiology:
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Male to female ratio 1:1.2
Majority in second decade
Resurgence in cases
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6 articles (1980-90); 50 (1991-2000), 121 (2000-2008)
Trend in publishing?
Antibiotic resistance
Antibiotic prescription patterns
Increased use of radiologic imaging
Lemierre’s Syndrome
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Pathogenesis:
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Primary infection
Infection of lateral pharyngeal space
Chirinos JA, Lichtstein DM, Garcia J et al. The Evolution of Lemierre’s Syndrome: Report of two cases and review of the literature.
Medicine. 2002; 81(6): 458-465.
Lemierre’s Syndrome
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Pathogenesis:
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Primary infection
Infection of lateral pharyngeal space
Virchow’s triad:
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Hypercoaguability
Venous stasis
Endothelial damage
Septic emboli
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Lung, joints (knee, hip, SC joint, shoulder)
Lemierre’s Syndrome
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Source:
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Tonsil, pharynx (URTI), chest (LRTI)
Karkos PD, Asrani S, Karkos CD, et al. Lemierre’s Syndrome: A Systematic Review. Laryngoscope. 2009; 119(8): 1552-9.
Lemierre’s Syndrome
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Signs/Symptoms:
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Most common presentation - sore throat
No significant neck findings - 47.7%
Karkos PD, Asrani S, Karkos CD, et al. Lemierre’s Syndrome: A Systematic Review. Laryngoscope. 2009; 119(8): 1552-9.
Lemierre’s Syndrome
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Microbiology:
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Primary agent: fusobacterium necrophorum
Other causes:
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Other fusobacteria
Anaerobic streptococci
Gram-negative anaerobes
Lemierre’s Syndrome
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Management:
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Operative debridement
Supportive care
Antibiotics:
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PCN, clindamycin, flagyl, and chloramphenicol
Beta-lactamase production
Anticoagulation
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Controversial -- no good studies
Platelet aggregation may be inhibited by aspirin
Lemierre’s Syndrome
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Presentation of NSTI:
Lemierre’s Syndrome
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Management of NSTI:
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Operative debridement (early and often)
Empiric antibiotics
Predictors of mortality
References
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Anaya DA, Dellinger EP. Necrotizing Soft-Tissue Infection: Diagnosis and Management. Clin Inf Dis. 2007;
44: 705-10.
Anaya DA, Bulger EM, Kwon YS, et al. Predicting Death in Necrotizing Soft Tissue Infections: A Clinical
Score. 2009; 10: 517-22.
Bondy P, Grant T. Lemierre’s Syndrome: what are the roles for anticoagulation and long-term antibiotic
therapy? Ann Oto Rhino Laryngol. 2008; 117(9): 679-83.
Boyer A, Vargas F, Coste F, et al. Influence of surgical treatment timing on mortality from necrotizing soft
tissue infections requiring intensive care management. Intensive Care Med. 2009; 35: 847-53.
Chirinos JA, Lichtstein DM, Garcia J et al. The Evolution of Lemierre’s Syndrome: Report of two cases and
review of the literature. Medicine. 2002; 81(6): 458-465.
Endorf FW, Cancio LC, Klein MB. Necrotizing Soft-Tissue Infections: Clinical Guidelines. J Burn Care Res.
2009; 30: 769-775.
Goldenberg NA, Knapp-Clevenger R, Hays T, et al. Lemierre’s and Lemierre’s-Like Syndromes in Children:
Survival and Thromboembolic Outcomes. Pediatrics. 2005; 116: 543-8.
Karkos PD, Asrani S, Karkos CD, et al. Lemierre’s Syndrome: A Systematic Review. Laryngoscope. 2009;
119(8): 1552-9.
Lemierre A. On certain septicemias due to anaerobic organisms. Lancet. 1936; 1: 701-3.
Ramirez S, Hild TG, Rudolph CN, et al. Increased Diagnosis of Lemierre Syndrome and Other
Fusobaterium necrophorum infections at a Children’s Hospital. Pediatrics. 2003; 112: 380-387.
Sarani B, Strong M, Pascual J, et al. Necrotizing Fasciitis: Current Concepts and Review of the Literature. J
Am Coll Surg. 2008; 10: 279-288.
Seyhan T, Ertas NM, Borman H. Necrotizing Fasciitis of the Chest Wall with a Retropharyngeal Abscess.
Annals Plastic Surg. 2008; 61: 544-8.
Silva DR, Gazzana MR, Albaneze R, et al. Septic pulmonary embolism secondary to jugular
thrombophlebitis: a case of Lemierre’s syndrome. J Bras Pneumol. 2008; 34(12): 1079-83.