A previously healthy 24-year-old woman comes to the emergency department because of fever, chills, and severe throat pain for the last 2 days. She reports having a sore throat 1 week prior, which did not resolve with amoxicillin therapy. She takes no other medications and denies any recent travel or illicit drug use.
Her temperature is 39.4 C (103 F), blood pressure is 90/62 mm Hg, pulse is 114/min, and respirations are 18/min. There is no skin rash. Oral examination reveals moist mucus membranes, erythema involving the oropharynx, and tonsillar enlargement without exudates. The right side of her neck is swollen and tender. There are no heart murmurs. There is no hepatomegaly or splenomegaly.
Laboratory results are as follows:

Chest x-ray reveals two round opacities in the right upper lung.
Which of the following is the most likely cause of this patient's current condition?

Question

A previously healthy 24-year-old woman comes to the emergency department because of fever, chills, and severe throat pain for the last 2 days.  She reports having a sore throat 1 week prior, which did not resolve with amoxicillin therapy.  She takes no other medications and denies any recent travel or illicit drug use.
Her temperature is 39.4 C (103 F), blood pressure is 90/62 mm Hg, pulse is 114/min, and respirations are 18/min.  There is no skin rash.  Oral examination reveals moist mucus membranes, erythema involving the oropharynx, and tonsillar enlargement without exudates.  The right side of her neck is swollen and tender.  There are no heart murmurs.  There is no hepatomegaly or splenomegaly.
Laboratory results are as follows:

Chest x-ray reveals two round opacities in the right upper lung.
Which of the following is the most likely cause of this patient's current condition?

Quizplus · Accepted Answer

11ec193a_9634_4c26_853d_d72fe2fe38a8_MD0002_00 This patient's clinical presentation is suggestive of septic thrombophlebitis involving the internal jugular vein (Lemierre's syndrome). Infection is usually caused by the anaerobic bacterium Fusobacterium necrophorum. Previously healthy young adults are most commonly affected, and present with pharyngitis or dental infection. The infection may improve spontaneously, extend to the lateral pharyngeal space, or involve the carotid sheath (e.g., internal jugular vein, internal carotid artery, vagus nerve) to produce a sepsis syndrome with a high mortality rate. The condition should be suspected in patients with a recent history of pharyngitis who develop neck pain, neck swelling, and persistent fever despite appropriate oral antibiotic therapy. Septic pulmonary emboli and other embolic phenomenon (e.g., arthritis, osteomyelitis) are common. Diagnosis is suggested by radiographic imaging showing internal jugular vein thrombophlebitis and is confirmed with blood or tissue cultures growing the causative oropharyngeal pathogen. Treatment usually involves 4 weeks of antibiotics that have anaerobic coverage, such as beta-lactams with beta-lactamase inhibitors (e.g., ampicillin-sulbactam), clindamycin, or carbapenems. (Choice B) Corynebacterium diphtheria infection usually presents with a sore throat with gray and white tonsillar exudates (pseudomembrane), cervical lymphadenopathy, fever, and sometimes cutaneous ulcers. The infection can extend into the neck and respiratory tract to cause respiratory distress. However, septic emboli are not seen. (Choice C) Infectious mononucleosis usually presents as a systemic illness with fever, fatigue, sore throat with tonsillar exudates, splenomegaly, and posterior cervical lymphadenopathy. This patient's lack of splenomegaly and presence of septic emboli make this diagnosis less likely. (Choice D) MRSA can cause skin infections and pneumonia, but it is a less common cause of pharyngitis. (Choice E) Mycobacterial infection can cause cervical lymphadenitis with neck swelling, but it is usually more gradual in onset without the sudden appearance of systemic symptoms as seen in this patient. Educational objective: Septic thrombophlebitis of the internal jugular vein should be suspected in patients with a recent history of pharyngitis who develop neck pain, neck swelling, persistent fever despite antibiotic therapy, and cavitary lung lesions. Infection is usually due to the anaerobic organism Fusobacterium necrophorum. Treatment involves 4 weeks of antibiotics with anaerobic coverage. __________ References: Lemierre's Syndrome (http://www.ncbi.nlm.nih.gov/pubmed/15192164)

A Previously Healthy 24-Year-Old Woman Comes to the Emergency Department