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.