Radiological Case of the Month FREE

Figure 1. Frontal chest radiograph shows diffuse patchy alveolar consolidation in the lung bases and bilateral pleural effusions.

Figure 2. Single axial computed tomography at the level of the liver shows a large, low-attenuation rounded lesion in the right lobe of the liver, abutting the capsular surface of the liver and with associated induration of the abdominal wall.

The blood culture grew anaerobic, gram-negative filamentous rods identified as Fusobacterium necrophorum, and antibiotic therapy was changed to cefepime and metronidazole. The CT scans revealed a large hepatic abscess involving the posterior segment of the right lobe. He had airspace consolidation in both lungs, with pleural effusions and a pneumatocele in the right lung. The hepatic abscess was drained percutaneously, and the pleural effusions were drained using bilateral chest tubes.

A neck CT scan demonstrated bilateral cervical lymphadenopathy, and Doppler ultrasonography showed internal jugular vein thrombosis or other venous abnormality. Findings from a CT scan of the head, a 2-dimensional echocardiogram, and a technetium-99m bone scan were normal. One week later a follow-up CT scan showed resolution of the liver abscess and improvement in lung aeration. He was discharged after a 3-week hospitalization, and he completed a 6-week course of antibiotic therapy. Findings from aerobic and anaerobic cultures from the hepatic abscess and pleural fluids were negative.

Lemierre syndrome, also known as necrobacillosis or postanginal septicemia, received its name from a comprehensive clinical description by Lemierre in 1936. The syndrome usually follows an acute oropharyngeal infection caused by F necrophorum (a constituent of normal flora) and secondary thrombophlebitis of the internal jugular vein and metastatic infection.¹ The illness occurs in previously healthy adolescents or young adults, starting with pharyngeal or tonsillar inflammation² and followed by recurrent fevers. The presence of jugular venous thrombophlebitis is considered a hallmark of the illness, though is not always present. Metastatic sequelae include pneumonia, pleural effusions, lung nodules and infarctions, septic arthritis, soft tissue abscesses, cellulitis, osteomyelitis, liver abscess, endocarditis, and meningitis.³ Thrombocytopenia and leukocytosis are present, and hepatic enzyme abnormalities with hyperbilirubinemia often are present.⁴ The organism is isolated from blood or other infected sites in anaerobic cultures. Lemierre syndrome is primarily a clinical diagnosis,⁵ although CT and ultrasound findings are sensitive in confirming the diagnosis.⁶ Recommendations for treatment include prolonged antibiotic therapy. Susceptibility testing to penicillin is important because of possible β-lactamase production.⁷ Invasive interventions are indicated to drain the purulent fluid collections.

Accepted for publication February 28, 2000.

Reprints: Umesh Narsinghani, MD, Department of Pediatrics, Critical Care Medicine, Arkansas Children's Hospital, 800 Marshall St, Slot #512-12, Little Rock, AR 72202-3591 (e-mail: narsinghaniumeshs@exchange.uams.edu).