2. Patient in ambulatory care
26 y.o. Male
Moroccan, in Canada x2 y
Married, works as manager at a wireless
phone company
CC: Right flank pain
PMH: none
Meds: none
Allergies: none
3. HPI
Day 1: headache
Day 2: nausea/vomiting, chills
Day 3: watery diarrhea. Chills.
Decreased urine output.
Day 4: goes to GP, given oral
rehydration and pepto bismol. Takes
tylenol and loratadine for symptoms.
Subsequently develops fever and
hematuria. No dysuria, frequency or
urgency
4. HPI
Day 5: presents to ED with R flank pain
radiating to back, chest pain, abdominal
pain, vomiting, diarrhea and frank
hematuria
No recent antibiotics, travel or exposure
to sick contacts
Self-limited sore throat with swollen
tonsils for 2 days that occurred 10 days
prior to ED visit. No rhinorrhea, no
hemoptysis
5. Physical exam
Triage vitals
HR 120, BP 103/47, RR 38, T 38.3
Looks unwell, dry mucus membranes, cracked
lips
GCS 15, no nuchal rigidity
No cervical lymphadenopathy
Chest clear
Normal S1 S2, no JVD, no murmur
Abdo diffusely tender maximally in lower
quadrants with some guarding. Bowel sounds
positive. Frank hematuria
Vitals after 2L bolus – HR 90, BP 96/56
12. Abdo US report
CONCLUSION:
Multiple hepatic cysts with a hypoechoic
liver lesion with cystic changes. This
should be further evaluated by MRI/CT
scan with contrast (if dialysis
considered).
Slightly enlarged spleen.
Enlarged and very echogenic kidneys,
consistent with renal medical disease,
consider acute glomerulonephritis.
13. Course in ED
Given total 6L of fluid
Consulted Medicine, ID, Nephro, GI
Patient on his way to the ICU
15. Course in hospital
Admitted to the ICU
Started on Timentin
Received hemodialysis
Clinical improvement
Discharge from ICU after 4 days
16. Differential diagnoses for renal
failure in this patient
Hemolytic Uremic Syndrome
Post-Streptococcal Glomerulonephritis
Sepsis-induced Acute Tubular Necrosis
17. HUS?
In favor
Diarrheal illness
Gram -ve rods in
blood
○ (? E. Coli 0157:H7)
Thrombocytopenia
Renal dysfunction
Fever, high WBC and
CRP
Not in favor
No anemia
No hemolysis
No other
microangiopathic
changes on smear
○ Teardrop cells
○ Helmet cells
○ Microspherocytes
18. PSGN?
In favor
Sore throat prior to
present illness
Decreased urine
output and fluid
overload
Gross hematuria and
proteinuria
Elevated ASOT
Renal ultrasound
consistent
Not in favor
No red cell casts on
microscopy
C3 and C4 levels
were later found to be
normal
Does not explain
other bacteremia and
GI symptoms
Renal biopsy
inconsistent
20. Sepsis
In favor
SIRS
Metabolic acidosis
Multisystem organ
dysfunction
○ GI symptoms
○ Elevated LFTs
○ Consumptive
coagulopathy
Gram -ve rods in blood
culture
Renal biopsy consistent
with ATN
A few unanswered
questions..
Why did someone so
young get sick so
quickly?
Why were so many
systems involved
despite no evidence of
immune suppression?
What was the
organism?
Was the sore throat a
red herring?
24. Epidemiology
F. Necrophorum causes endemic
pharyngitis
Primarily adolescents and young adults (16-30)
incidence of 10% (equal to group A strep)
~1 in 400 cases of F. Necrophorum
pharyngitis can lead to systemic
necrobacillosis and Lemierre’s syndrome
Mortality 4.6%
Resurgence in last 15 years
25. Pathophysiology
Pharyngitis caused by
Fusobacterium Necrophorum primarily
Another organism (e.g. GAS) with
secondary colonization by F. Necrophorum
26. Pathophysiology
Invades blood vessels in parapharyngeal
space causing bacteremia with a wide
range of presentations
Classic fulminating Lemierre's syndrome
○ IJ thrombus
○ Rapid dissemination of septic microemboli to
lung, joints, intraabdominal organs, and CNS
Transient bacteremia which leads weeks
later to a focal abscess
Toxin production leading to sepsis with
thrombocytopenia and DIC
27. What can be done about it?
Necrobacillosis and LS are preventable
Think about it when seeing a young person
with a sore throat
Consider throat culture for other organisms
besides Strep
Red flags for pharyngitis
Symptoms do not resolve in 3-5 days
Symptoms rapidly worsen
Unilateral neck swelling
Systemic symptoms (e.g. Bacteremic)
Treat with penicillin/flagyl or clindamycin
28. References
Marx: Rosen's Emergency Medicine, 7th ed. - 2009 - Mosby, An Imprint
of Elsevier.
Riordan T. Human infection with Fusobacterium necrophorum
(Necrobacillosis), with a focus on Lemierre’s syndrome. Clin
Microbiol Rev. 2007;20:622- 59. [PMID: 17934077]
Centor RM. Expand the Pharyngitis Paradigm for Adolescents and
Young Adults. Annals of Internal Medicine. 2009;151(11):812-5
Batty A, Wren MW. Prevalence of Fusobacterium necrophorum and
other upper respiratory tract pathogens isolated from throat swabs.
Br J Biomed Sci. 2005;62:66-70
Amess JA, O’Neill W, Giollariabhaigh CN, Dytrych JK. A six-month
audit of the isolation of Fusobacterium necrophorum from patients
with sore throat in a district general Hospital. Br J Biomed Sci.
2007
Hagelskjaer Kristensen L, Prag J. Lemierre’s syndrome and other
disseminated Fusobacterium necrophorum infections in Denmark: a
prospective epidemiological and clinical survey. Eur J Clin Microbiol
Infect Dis. 2008;27:779-89
29. References
Syed MI, Baring D, Addidle M, Murray C, Adams C
(September 2007). "Lemierre syndrome: two cases
and a review". The Laryngoscope (The American
Laryngological, Rhinological & Otological Society;
Lippincott Williams & Wilkins) 117 (9): 1605–1610
Screaton NJ, Ravenel JG, Lehner PJ, Heitzman ER,
Flower CD (November 1999). "Lemierre Syndrome:
Forgotten but Not Extinct-Report of Four
Cases". Radiology (Radiological Society of North
America) 213 (2): 369–374
Beldman TF, Teunisse HA, Schouten TJ (November
1997). "Septic arthritis of the hip by Fusobacterium
necrophorum after tonsillectomy: a form of Lemierre
syndrome?". European journal of pediatrics (Springer-
Verlag) 156 (11): 856–857