Case Report
A previously healthy 16-year old male was admitted to hospital following
two weeks of fever, myalgia, malaise, nausea/vomiting/diarrhea
associated with 10-pound weight loss, and a dry cough. He had been
evaluated by his primary care provider (PCP) ten days prior to admission
for complaints of sore throat and fever up to 40oC.
Rapid streptococcal antigen and SARS-CoV-2 testing were negative, and he
was treated with antipyretics. Continued symptoms led to reevaluation by
his PCP 7 days later. A chest radiograph at that time revealed a single
round pneumonia in the right lower lobe and he was treated with 3 days
of oral azithromycin. He failed to improve and was referred to the
emergency department 3 days later, where a computed tomography (CT) scan
of the chest/abdomen/pelvis demonstrated diffuse, bilateral, cavitary,
pulmonary nodules. Physical examination at the time was significant only
for multiple ulcerative lesions of the oropharynx. He was admitted for
further evaluation and treatment, including empiric therapy with
intravenous vancomycin and ceftriaxone.
Considerations from the admitting team included atypical infection
(fungal or mycobacterial) versus e-cigarette or vaping product use
associated lung injury (EVALI), so the pulmonary medicine service was
consulted. EVALI was thought to be unlikely based on the radiographic
appearance of the lesions (Figure 1). Additional diagnostic
considerations included septic emboli, paragonimiasis, autoimmune
disease with small vessel vasculitis (polyangiitis with granulomatosis),
and inflammatory bowel disease. Comprehensive evaluation for the above
potential diagnoses was initiated and empiric therapy with vancomycin
and ceftriaxone was continued. Echocardiogram, infectious diseases
testing, and rheumatic evaluation were all normal other than elevation
of his C-reactive protein. The day following admission, he developed
tender swelling in the right, anterior neck as well as a tender spot on
his upper right back. His blood culture grew gram-negative anaerobic
rods, raising concern for Lemierre’s syndrome. A Doppler ultrasound of
the neck demonstrated occlusive thrombus within the right external
jugular vein with nonocclusive extension into the internal jugular vein.
Metronidazole was added to his intravenous antimicrobial regimen and
anticoagulation therapy was initiated.
Additional imaging demonstrated normal CT scan of the head with
confirmation of the ultrasound findings of thrombosis of the jugular
veins as well as marked inflammation over the surrounding soft tissues
of the anterior right neck and a large abscess involving the posterior
spinal musculature of the upper thorax. A percutaneous drain was placed,
and 25 cc of purulent material was removed. Magnetic resonance imaging
of the spine revealed possible extension of the abscess into the T1
spinous process concerning for osteomyelitis. The blood culture was
finalized as growing Fusobacterium necrophorum and antibiotic
coverage was changed to ampicillin/sulbactam to better treat potential
polymicrobial infection. Fevers resolved, discomfort and other symptoms
improved, and the percutaneous drain was removed after 3 days. He was
discharged home to continue with 6 weeks of continuous infusion
ampicillin/sulbactam and anticoagulation therapy.