Lemierre-Like Syndrome: A Series of Unique Cases

A previously healthy 17-year-old white girl initially presented to a local urgent care with 2 days of headache, sore throat, and fever of 104°F. Rapid Group A Streptococcus testing on a pharyngeal swab was negative, and her complete blood count (CBC) revealed a white blood cell count (WBC) of 18 300 mm-3, with 91% neutrophils. Hemoglobin (Hgb) was 14 g/dL, hematocrit 41%, and platelet count 194 000 mm-3. She was diagnosed with a viral illness and discharged home with supportive therapy. Her fever and sore throat persisted, and on day 5 of illness, she developed pain in her left chest and right hip. An urgent care facility practitioner prescribed supportive care. Over the next few days her chest and hip pain increased, and she could not bear weight on her right leg. On the eighth day of illness, she presented to a community hospital emergency room with significant pain in her hip and chest and hypovolemic shock. She had a marked leukocytosis of 40 000 mm-3, with 50% neutrophils, 32% bands, 4% lymphocytes, 1% eosinophils, 1% monocytes, 9% metamyelocytes, and 3% myelocytes. In addition, there was evidence of disseminated intravascular coagulation and elevated blood urea nitrogen, creatinine, and pancreatic and hepatic enzymes. After aggressive fluid resuscitation and hospitalization, her empirical therapy included IV vancomycin, clindamycin, and ceftriaxone. A chest CT scan revealed a large left-sided empyema with multiple septic emboli and nodularity of the thymus. Because of a concern for possible malignancy, she underwent diagnostic thoracocentesis and bone marrow aspiration. CT scan of her lower extremity confirmed a diagnosis of necrotizing fasciitis. She underwent extensive debridement of her right buttock, flank, and thigh (Figure 1). Her blood, wound, and pleural fluid cultures grew Fusobacterium necrophorum and Peptostreptococcus. She was empirically started on low-molecular-weight heparin, although there was no evidence of thrombosis. Postoperatively, she developed acute respiratory distress syndrome, required multiple chest tubes to drain pleural effusion, and multiple blood products. Her lowerextremity wound required repeated surgical debridement and vacuum-assisted wound closure. She remained in hospital for 7 weeks during which her parenteral therapy included 3 weeks of vancomycin, 6 weeks of clindamycin, 10 days of penicillin, and 2 weeks of liposomal amphotericin B for catheter-related