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LETTER TO EDITOR
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 49-50

Lemierre's syndrome with chest wall metastasis caused by klebsiella pneumonia


Department of General Medicine, M.E.S. Medical College, Perinthalmanna, Kerala, India

Date of Submission21-Mar-2021
Date of Acceptance24-May-2021
Date of Web Publication03-Jul-2021

Correspondence Address:
Prof. Mansoor C Abdulla
Department of General Medicine, M.E.S. Medical College, Perinthalmanna, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aiao.aiao_6_21

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How to cite this article:
Abdulla MC. Lemierre's syndrome with chest wall metastasis caused by klebsiella pneumonia. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2021;5:49-50

How to cite this URL:
Abdulla MC. Lemierre's syndrome with chest wall metastasis caused by klebsiella pneumonia. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2021 [cited 2021 Jul 25];5:49-50. Available from: https://www.aiaohns.in/text.asp?2021/5/1/49/320576



Sir,

Lemierre's syndrome (LS) is life-threatening, but a rare complication of oropharyngeal infection. LS is characterized by sepsis, often with an oropharyngeal source, secondary septic emboli, and internal jugular vein thrombosis.

A 56-year-old housewife was admitted with low-grade fever and sore throat for 14 days. Two days after, the fever and sore throat she developed pain over the right side of the neck and headache. She had no sick contacts and had no history of addictions. She had diabetes, systemic hypertension, bipolar affective disorder, and hypothyroidism for 17 years. On examination, she had a fever of 100°F, no tachycardia, no tachypnea, and normal blood pressure. There was no erythema, swelling, or exudates in the pharynx. There was no evidence of otitis media, gingivitis, and dental caries. Neck examination showed tender cord-like swelling with ill-defined margin present over the right side of the neck. She had mild tenderness over the right upper chest wall. The rest of the examination was unremarkable.

Hemoglobin was 10.5 g/dl (normocytic and normochromic), total leukocytes count 11,130/ml with 86% neutrophils, platelet count 3, 40,000/μl, erythrocyte sedimentation rate 43 mm in 1 h, and c reactive protein was high. Fasting blood sugar was 323 mg/dl and hemoglobin A1c was 14. Rest of the blood chemistries were normal. Chest X-ray was normal. HIV, hepatitis B, and hepatitis C serologies were negative. Contrast-enhanced computed tomography scan of the head and neck with contrast demonstrated a filling defect in the right internal jugular vein and edema around the soft tissues of the neck [Figure 1]. Thorax contrast-enhanced computed tomography showed a 2.2 cm × 2.8 cm abscess over the right upper anterior chest wall. Blood and pus cultures showed growth of Klebsiella pneumonia [Figure 2]. She was diagnosed to have Lemierre's Syndrome with chest wall metastasis secondary to Klebsiella pneumonia. She was started initially on amoxicillin-clavulanic acid with clindamycin which was changed to piperacillin tazobactam and ciprofloxacin based on the culture report. She improved completely following 3 weeks of antibiotics. Repeat computed tomogram of the thorax after 4 weeks showed completely resolved abscess.
Figure 1: Contrast-enhanced computed tomography scan of the head and neck with contrast showing a filling defect in the right internal jugular vein and edema around the soft tissues of the neck

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Figure 2: (a) Contrast-enhanced computed tomography scan of the thorax showing a 2.2 cm × 2.8 cm abscess over right upper anterior chest wall. (b) Computed tomography scan of the thorax showing complete resolution of the abscess

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LS is a rare disease, which is seen usually secondary to lethal anaerobic septicemia caused by Fusobacterium necrophorum.[1] The common infections associated with LS are (87.1%), mastoiditis (2.7%), and odontogenic infections (1.8%).[2] Fusobacterium species, such as F. necrophorum and nucleatum are the organisms which are usually responsible for LS. However, the association of LS with other organisms such as Streptococcus, Bacteroides, Eikenella corrodens, Enterococcus, Peptostreptococci, Proteus mirabilis and many more was reported previously.[3]

The association of Klebsiella pneumoniae with LS was reported previously and most of the patients had poorly controlled diabetes mellitus.[4] Hyperglycemia can impair the phagocytic function of neutrophils increasing the risk of Klebsiella infections. Metastatic infection following LS commonly occurs to the lungs and joints. Metastatic infections involving the liver, muscle, pericardium, brain, and skin have also been described.[5] Metastatic infections in Klebsiella. pneumoniae-associated LS were common in the lungs and brain.[4] Our patient had Klebsiella. pneumoniae-associated LS with isolated metastatic infection to the chest wall which completely resolved following antibiotics alone. Routine use of anticoagulation in LS is controversial. LS patients having clot propagation involving the cavernous sinus or having septic emboli can be considered for anticoagulation.[6] Our patient had improvement with antibiotics alone. The case is presented for the following reasons; (1) K. pneumoniae associated LS is rare. (2) Isolated metastatic infection to the chest wall without lung parenchymal involvement was not previously reported. (3) Patient had complete recovery following antibiotics alone without anticoagulation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bird NT, Cocker D, Cullis P, Schofield R, Challoner B, Hayes A, et al. Lemierre's disease: a case with bilateral iliopsoas abscesses and a literature review. World J Emerg Surg 2014;9:1-7.  Back to cited text no. 1
    
2.
Ramirez S, Hild TG, Rudolph CN, Sty JR, Kehl SC, Havens P, et al. Increased diagnosis of Lemierre syndrome and other Fusobacterium necrophorum infections at a Children's Hospital. Pediatrics 2003;112:e380.  Back to cited text no. 2
    
3.
Riordan T. Human infection with Fusobacterium necrophorum (necrobacillosis), with a focus on Lemierre's syndrome. Clin Microbiol Rev 2007;20:622-59.  Back to cited text no. 3
    
4.
Chuncharunee A, Khawcharoenporn T. Lemierre's syndrome caused by Klebsiella pneumoniae in a diabetic patient: A case report and review of the literature. Hawaii J Med Public Health 2015;74:260-6.  Back to cited text no. 4
    
5.
Takeda K, Kenzaka T, Morita Y, Kuroki S, Kajii E. A rare case of Lemierre's syndrome caused by Porphyromonas asaccharolytica. Infection 2013;41:889-92.  Back to cited text no. 5
    
6.
Wright W, Shiner C, Ribes J. Lemierre syndrome. South Med J 2012;105:283-8.  Back to cited text no. 6
    


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