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Final ID: Poster #: CR-001

Methicillin-resistant staphylococus aureus in Lemierre's syndrome: a rare cause of a rare syndrome in pediatric patients

Purpose or Case Report:
Lemierre’s syndrome is an extremely rare condition characterized by initial oropharyngeal infection with development of septic thrombophlebitis and subsequently disseminated septic microemboli. The syndrome remains a disease of considerable morbidity and mortality. The incidence is approximately 3.6 cases per 1 million per year. It is commonly caused by gram-negative Fusobacterium necrophorum. However, less than a third of cases is brought on by other anaerobic bacteria. Here we present a rare case of a Lemierre’s syndrome in a child caused by methicillin-resistant Staphylococcus aureus (MRSA).

A 4-year old male presented to emergency department with unremitting fever, progressive painful submandibular swelling concerning for Ludwig’s angina, vesicular lesions on the skin, and decreased level of consciousness. The patient was reported to have fallen onto his chin with resultant lip laceration and tooth avulsion. Fever and neck swelling developed two days later. Computed tomography (CT) of the neck revealed findings in keeping with clinically suspected Ludwig’s angina including: soft tissue gas, and diffuse fat stranding involving the sublingual, perioral, and right submandibular spaces with extension to right sternoclavicular muscle, carotid and jugular vessels. No abscess was identified but a focal non-occlusive thrombus was seen in the right internal jugular vein. Additionally, the lung apices demonstrated multiple patchy densities raising concern for Lemierre’s syndrome and prompting further evaluation with a contrast-enhanced chest CT. Chest CT confirmed the diagnosis demonstrating multiple, variable-sized, randomly distributed lung nodules with cavitation, and multifocal consolidation consistent with septic emboli. Blood culture and skin swab of vesicular lesions were positive for MRSA. On further discussion, it was revealed that the patient’s father was recently treated for MRSA abscess. The patient was placed on intravenous antibiotics (vancomycin, rifampin, meropenem) and anticoagulants (tinazaparin) with improvements in symptoms and imaging findings within six weeks post admission.

The learning points include:
1) the need to critically evaluate lung apices and vasculature on neck CT in patients with evidence of soft tissue neck/oropharyngeal infection
2) despite the rarity of Lemierre’s syndrome, multiple cases caused by MRSA have been described.
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