Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Case of T.C.: Presentation, Evaluation and Management of Lemierre’s Syndrome Patient TC 16 year old male CC: anterior chest wall swelling and RLE pain HPI: 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 PMH: None, no prior hospitalization PSH: None FH: No sick contacts. Non-contributory. SH: Lives in Renton with parents, sister. ROS: - : fever, headache, rash + : fatigue, congestion, cough, mild dyspnea, anorexia, nausea, diarrhea, decreased UOP, jaundice Patient TC PMH: None, no prior hospitalization PSH: None FH: No sick contacts. Non-contributory. SH: Lives in Renton with parents, sister. ROS: - : fever, headache, rash + : fatigue, congestion, cough, mild dyspnea, anorexia, nausea, diarrhea, decreased UOP, jaundice Patient TC OSH Course: Pan CT: 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 OSH Course: Pan CT: 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 ED Presentation: Per report, enlargement of chest wall swelling enroute PE: 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 Left pectoralis indurated with TTP and purulent drainage over medial clavicle Abd: Hepatomegaly Ext: RLE edematous with pain on dorsiflexion Patient TC ED Presentation Labs: 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 ED Presentation Labs: 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 OR Findings: Purulent material with crepitus Erosion of sternoclavicular joint Initial compartment pressures: 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 Hospital Course 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 3 chest tubes placed on right on HD 2 Additional chest tube on left on HD 5 Patient TC Hospital Course Blood cultures - negative Wound/Tissue cultures - grew abundant fusobacterium species Neck U/S (HD #2): Superior to mid IJ completely occluded Thrombosed with small amount of flow Inferior portion has collateral flow Patient TC Patient TC Hospital Course Blood cultures - negative Wound/Tissue cultures - grew abundant fusobacterium species Neck U/S (HD #2): 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 Definition: History of oropharyngeal infection Clinical/radiographic IJ vein thrombosis Isolation of anaerobic pathogens Metastatic abscesses History: 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 Epidemiology: Male to female ratio 1:1.2 Majority in second decade Resurgence in cases 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 Pathogenesis: 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 Pathogenesis: Primary infection Infection of lateral pharyngeal space Virchow’s triad: Hypercoaguability Venous stasis Endothelial damage Septic emboli Lung, joints (knee, hip, SC joint, shoulder) Lemierre’s Syndrome Source: 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 Signs/Symptoms: 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 Microbiology: Primary agent: fusobacterium necrophorum Other causes: Other fusobacteria Anaerobic streptococci Gram-negative anaerobes Lemierre’s Syndrome Management: Operative debridement Supportive care Antibiotics: PCN, clindamycin, flagyl, and chloramphenicol Beta-lactamase production Anticoagulation Controversial -- no good studies Platelet aggregation may be inhibited by aspirin Lemierre’s Syndrome Presentation of NSTI: Lemierre’s Syndrome Management of NSTI: Operative debridement (early and often) Empiric antibiotics Predictors of mortality References 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.