Infectious diseases conference

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Infectious diseases conference

• February 9th 2004
• Charles de Comarmond MD
• Infectious Diseases Fellow

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History of present illness

• 18 year old previously healthy AAM, admitted on
  12/28/03 with cough and SOB
• Onset of upper respiratory tract symptoms
  approximately two weeks prior to admission
• Symptoms progressed with development of
  productive cough associated with brownish sputum
  expectoration and chest pain
• Also reported SOB and fevers

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History of present illness

• Also c/o nausea and anorexia with 10 Lb weight
  loss
• Seen in outside facility and found to have
  abnormal CXR.
• CT chest done at Baptist demonstrated multiple
  pulmonary cavitary lesions

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PMHx, Social Hx, Family Hx

• Previously healthy
• Currently a nursing student at WSSU
• Born in Jamaica but immigrated to the US 10 years
  ago, lived in New York and Florida only. Denies
  any recent travel outside of NC
• Family history non contributory

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Physical exam
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Physical exam

• Appearance Comfortable, no signs of
  respiratory distress
• Skin No rash
• HEENT PERLA, fundii normal, scattered
  thrush in oropharynx
• Neck Supple, no palpable mass.

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Physical exam

• Lymph nodes scattered shotty anterior and
  posterior chain cervical lympadenopathy,
  left gt right, Palpable bilateral axilla lymph
  nodes and inguinal nodes.
• Chest Scattered crackles
• Heart S1S2 RRR, systolic 2/6 murmur
• Abdomen Normal
• Extremities Normal muscle bulk
• Neuro AAO x 3, no focal deficit

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Labs
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Objectives

• Definition of septic thrombophlebitis
• Microbiology
• Clinical signs and symptoms
• Diagnosis
• Treatment

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Lemierres Syndrome

• First description by Courmont Cade 1900
• A. Lemierre -earliest case review of 20 patients
  in 1936

Lancet 1936 1701-703
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Epidemiology

• Lemierre's syndrome is rare. In a Danish
  retrospective study, the incidence was 1 case per
  million per year
• Young, healthy adolescents and young adults (mean
  age 18-20 years)
• Male predominance (75)

• Eur J Clin Microbiol Infect Dis 1998 17561 5
• Arch of Otolarnygo Vol 126, No 12, Dec 2000.

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Epidemiology

• A recent publication by Belongia et al
  demonstrated that multifaceted education programs
  for clinicians and parents led to an overall
  decrease in antibiotic prescriptions of
  approximately 20 in northern Wisconsin between
  1997 and 1998
• The increase in the number of patients infected
  with F necrophorum occurred during the last 2 of
  the 7 years that were analyzed in the study, 1
  year after the initiation of the WARN campaign
• The increase in LS could also be attributable to
  the increasingly judicious use of antibiotics in
  Wisconsin or a change in the antibiotic
  susceptibility pattern of the organism.

PEDIATRICS Vol. 112 No. 5 November 2003, pp.
e380-e380
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Pharyngotonsillitis
Impaired mucosal defense
Peritonsillar veins thrombophlebitis
Septic thrombosis of internal jugular vein
Septic embolic events
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Microbiology

• Fusobacterium necrophorum most common organism
  (81 of cases)
• spindle-shaped rod which brings death
• F. necrophorum is a strictly anaerobic,
  nonmotile, non-spore-forming, Gram-negative rod
• It has a characteristic pleomorphic morphology on
  Gram-stained smears, with filaments, short rods,
  and coccoid elements

• Arch of Otolarnygo Vol 126, No 12, Dec 2000.

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Microbiology

• One-third of patients with Lemierre's syndrome
  have polymicrobial bacteremia
• The concomitant bacteria are mostly oropharyngeal
  microbiota, such as
• Peptostreptococci,
• Nonhemolytic streptococci
• Microaerophilic streptococci
• Hemolytic streptococci of groups A, B, and C

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Alvarez A, Schreiber JR. Lemierres syndrome in
adolescent children-anaerobic sepsis with
internal jugular vein thrombophlebitis following
pharyngitis. Pediatrics 1995354-359.
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Culture plate
Gram stain
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Scanning EM of fusobacterium
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Clinical signs and symptoms

• The appearance and repetition several days after
  the onset of a sore throat (and particularly of a
  tonsillar abscess) of severe pyrexial attacks
  with an initial rigor, or still more certainly
  the occurrence of pulmonary infarcts and
  arthritic manifestations, constitute a syndrome
  so characteristic that mistake is almost
  impossible

Lemierre, Lancet 1936 1701-703
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Clinical signs and symptoms

• The first clue to the diagnosis in 69.7 of the
  cases we reviewed was the finding of F.
  necrophorum in blood culture results rather than
  the clinical signs or symptoms.
• The lungs are most common metastatic target
  (79.8 of cases), followed by the joints (16.5
  of cases)
• Fever is common (82.5 of cases)

Medicine 2002 81(6)458-465
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Clinical signs and symptoms

• Other sites of septic dissemination reported
  include hepatic or splenic abscesses (2.7 of
  cases)
• Splenomegaly and hepatomegaly are common (15.5)
  and are not necessarily associated with liver or
  hepatic abscesses

Medicine 2002 81(6)458-465
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Clinical signs and symptoms

• Pharyngeal infection pharyngitis, trismus,
  odynophagia, neck pain, tenderness, swelling,
  cervical adenopathy, /- exudate
• Jugular vein phlebitis lateral neck/jaw pain,
  tender mass along SCM muscle, cord sign Signs
  of septicemia, embolism, DIC
• Local findings may be absent 47 of patients in
  one series (n109) did not have local symptoms

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Clinical signs and symptoms

• Hematologic
• Hyperbilirubinemia
• Transaminitis
• Renal Failure/ Proteinuria/Hematuria
• Pleuropulmonary Disease
• Osteomyelitis
• Oligoarthritis
• Soft Tissue Infection
• Vesiculopustular Rash

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Diagnosis

• Physical Examination
• Head, neck, anterior border of SCM
• Blood Culture
• Anaerobic culture of body fluids
• Imaging
• Chest Xray
• I Neck/Chest/Abdominal CT
• Neck Ultrasound
• Magnetic Resonance Imaging

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Diagnosis/Imaging

• Associated pleural effusions are common (43.1 of
  patients) and may precede the appearance of
  pulmonary infiltrates.
• A normal chest X-ray was present in 19.2 of
  cases, and only 31.1 of patients had radiologic
  evidence of cavitation.
• Moreover, almost half (44.2) of these cases of
  cavitation were not evident on follow-up plain
  chest films, and were demonstrated only by CT
  scans of the chest.
• Frank respiratory failure requiring ventilatory
  support occurred in 15.5 of cases.

Medicine 2002 81(6)458-465
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Treatment

• F necrophorum is usually susceptible to
  penicillin, clindamycin, metronidazole, and
  chloramphenicol.
• Susceptibility to cephalosporins, erythromycin,
  and tetracyclines is variable.
• Resistant to aztreonam and trimethoprin-sulfametho
  xazole, as well as aminoglycosides.
• Penicillin treatment failures have been reported,
  presumed to be caused by ß-lactamase production.

Pediatr Infect Dis J.1990 9 505 508 Clin
Infect Dis.2000 31 524 532 Postgrad Med
J.1999 75 141 144 Medicine.1989 68 85 94
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Treatment

• In 1990, Appelbaum et al. found 40 of
  Fusobacteria isolates to elaborate ß-lactamase.
• F nucleatum and F necrophorum accounted for gt40
  of ß-lactamase producers.
• Therefore, most experts recommend the use of
  ß-lactamase-resistant antibiotics with anaerobic
  activity such as intravenous ticarcillin-clavulana
  te, ampicillin-sulbactam, metronidazole, or
  clindamycin.

Pediatr Infect Dis J.1993 12 532 533
Pediatrics.1995 96 354 359 Antimicrob Agents
Chemother.1990 34 1546 1549
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Treatment

• Duration 4-8 wks until resolution of pulmonary
  abscesses
• Anticoagulation
• No randomized controlled trials
• Anecdotal supportive treatment
• Surgical Intervention
• Ligation excision of jugular vein
• Open drainage
• VATS

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Prognosis

• Mortality Rate in Lemierres series 90
• Mortality today 4-18
• Prognosis related to prompt initiation of therapy
  Delayed defervescence prolonged course common

Medicine 2002 81(6)458-465