Case Report: 18 year old with increasing neck mass

Answer: Neck abscess caused by Fusobacterium necrophorum

The patient was found to have an abscess on CT scan 4.7cm x3.8cm x 9cm. Initially mass was aspirated with 10cc of foul-smelling purulence removed. The Gram stain revealed Gram negative bacilli. The patient was brought to OR for incision and drainage. She was left on approximately 3-4 weeks of IV antibiotics with ceftriaxone 2gm daily.

Fusobacterium species are oral non-spore forming anaerobes are associated with posterior pharynx infections, including tonsillitis caused by Strep or mononucleosis (EBV). The most common life-threatening condition that Fusobacterium is associated with is Lemierre’s syndrome (70% of cases), a postanginal syndrome (post-sore throat) characterized by septic thrombophlebitis of the jugular vein (usually internal jugular vein) and subsequent septic emboli to the lungs. These emboli can lead to pulmonary parenchymal infection, resulting in an empyema (a pus-pocket in the pleural space around the lungs), that typically requires an intervention such as a Video-assisted thorascopic surgery (VATS) or a mini-thoractomy to remove the pleural rind and drain the abscess.

Pleural space with fluid (pleural effusion), source Wickepedia

It is important to consider this syndrome in any patient that is presenting with a sore throat (current or recent), neck pain and shortness of breath, tachypnea (rapid-breathing), chest pain and/or hypoxia (low oxygen), as it can be associated with a mortality risk and need for an intervention. Treatments such as medrol dose pack, commonly used for viral infections, can blunt the inflammatory response, often leading to more severe presentations. Although Fusobacterium is generally susceptible to beta-lactams (e.g. penicillin or amoxicillin) there may be resistance from beta-lactamase production (up to 40% in one study).

Another patient with advanced pulmonary disease from Fusobacterium. He presented with sore throat, neck pain and shortness of breath
His CT scan showing empyema both posterior lungs and pleural-pericardial area

Regarding the questions:

  1. Risk factors: most important was the medrol dose pack. The viral infection (likely given viral exanthem) was a risk factor as well. Least likely is her chronic lamictal, although it can be associated with granulocytopenias and some degree of immunocompromise.
  2. Other study: She has hypoxia which is not accountable otherwise. A chest radiograph would be important. Sometimes, I recommend a CT scan in a patient with chest pain, audible crackles when I am considering Lemierre’s syndrome. The x-rays can be very limited.
  3. Her fever may be blunted from the steroids which are febrolytic. Other medications to screen a patient if they are taking include nonsteroidals and acetaminophen.
  4. Process is known as Lemierre’s syndrome associated with septic internal jugular venous thrombosis and septic pulmonary emboli, which could lead to empyema.

I hope that you enjoyed reviewing this case. I will plan to present 1 to 2 cases monthly. In this section, we will also include short case vignettes, photos for “what is the diagnosis” and board review questions. Please share with your friends.

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