Lemierre’s Syndrome Presenting as a Case of Perforated Otitis Media Vadim Fradlis, DO 1 ; Maya Haasz, MD 2 Department of Emergency Medicine 1 Department of Pediatrics 2 St. Barnabas Hospital, Bronx, NY. Chief Complain & Presentation:. Radiological Findings:. Heme:
Lemierre’s Syndrome Presenting as a Case of Perforated Otitis MediaVadim Fradlis, DO1; Maya Haasz, MD2Department of Emergency Medicine1Department of Pediatrics2St. Barnabas Hospital, Bronx, NY
Chief Complain & Presentation:
A previously healthy 5 year old male presented with one day history of tactile fevers and bleeding from the left ear with associated otalgia and cervicalgia. Pain was localized to the L infra-auricular region and described as sharp, non-radiating, woke him up from sleep and was aggravated by neck movement. As per the family, the child woke up with purulent & bloody discharge from the left ear on the day of presentation. The patient’s grandmother reported a history of vomiting, diarrhea and non-specific abdominal pain two days prior which had since resolved. She also reported decreased PO intake. There was no history of sick contacts, recent travel, neck trauma, sore throat, odynophagia, tinnitus, rashes, cough, dyspnea, headaches or recent antibiotic use.
Past Medical Hx: Recurrent acute otitis media
Past Surgical Hx: None
Immunizations: Up to date
General: Non-toxic, calm, minimal distress
HEENT: NC/AT, PERRLA, pupils 3mm b/l, dry mucous membranes, erythematous slightly enlarged tonsils with minimal exudates, no pseudo-membranes, vesicles or ulcers; serosanguenous left otorrhea, inability to visualize left TM due to edematous & purulent external auditory canal & effusion
Neck: Tenderness along left sternocleidomastoid to cervical paravertebral muscles, no mastoid tenderness; soft & supple with no discreet masses but with restricted ROM due to pain, notable trismus, no lymphadenopathy
CVS: RRR, normal S1/S2, no M/G/R
Pulmonary: CTA b/l, no W/R/R, b/l equal air entry
GI: Soft, NT/ND, no guarding, no rebound, + BS
Skin: Dry, warm with no rashes or petechia
Neurologic: CN II – XII grossly intact, 5/5 muscle strength b/l upper and lower extremities, negative Kernigs & Brudzinskis signs.
CT: septic thrombus extending from distal portion of the left transverse sinus, the siphon, & proximal portion of the IJ vein
MRI: thrombophlebitis involving the left sigmoid sinus and left otomastoiditis
Temp: 102.2ºFBP: 93/55 HR:139 RR: 20SpO2: 100% on RA
Emergency Department & Hospital Course:
Bondy P, Grant T. Lemierre’s syndrome: What are the roles for anticoagulation and long-term antibiotic therapy? Ann Otol Rhinol Laryngol. 2008;117:679–83.
Goldenberg, NA, Knapp-Clevenger, R, Hays, T, and Manco-Johnson, MJ. Lemierre’s and Lemierre’s-Like Syndromes in Children: Survival and Thromboembolic Outcomes. Pediatrics 2005;116:e543–e548.
Ridgway JM, Parikh DA, Wright R, et al. Lemierre syndrome: a pediatric case series and review of literature. Am J Otolaryngol 2010; 31:38.
Ruirdan T. Human infection with Fusobacterium necrophorum (Necrobacillosis) with a focus of Lemierre’s syndrome. Clin Microbiol Rev. 2007;20:622–59
Weeks DF, Katz DS, Saxon P, et al. Lemierre syndrome: report of five new cases and literature review. Emerg Radiol 2010;17:323Y328.
LDH: 337 IU/L ESR: 60 mm/Hr
Fibrinogen: 578 mg/dl Lactic Acid: 1.1
D-dimer: 3.81 mg/L Blood Culture: negative