19M brought into pediatric resus looking toxic, diaphoretic with shallow breathing.  Temp 38.7, HR 126, BP 146/51,  RR 20,  95% on RA. Two weeks ago he had a sore throat which was strep and monospot negative.  He’s had a persistent sore throat with fever progressing to trismus, right mandibular numbness, neck stiffness, and now with pleuritic chest pain and LUQ tenderness on exam.  No known immune compromise.  What imaging would you choose? Antibiotics seem like a good idea; what would you choose? What disease entity ties all this together?

This is a case that comes from UCLA. This patient’s blood cultures eventually grew out Fusobacterium necrophorum – a gram negative anaerobe, and the clinical entity is Lemierre’s Syndrome – which is basically extension of an oropharyngeal infection (most often Fusobacterium) into the jugular vein with resultant septic emboli.

-the patient got contrast CT of his neck and chest which showed a right sublingual abscess near the right jugular. There was a shower of septic emboli affecting the lungs and spleen.

-with a presentation suggestive of Lumierre’s, the recommendation is antibiotic coverage for beta-lactamase resistance and anaerobes. The docs at UCLA started with meropenam and metronidazole.

-anticoagulation is controversial (you can defer that one)

-about 75% of cases are in the age group 16-25

-this patient recovered with 4 weeks of antibiotic therapy

-put this one on the mental list where you keep peritonsillar/retropharyngeal abscess, Ludwig’s angina