Spitting Out Blood

A middle-aged woman presented to the ED with right-sided neck pain that she had developed that day. She reported that she had spit out a lot of blood, but denied fevers, chills, chest pain, shortness of breath, nausea, and vomiting. She said she hadn't felt well for the past few days.   The CT gives the answer.       The patient had a thrombosed right internal jugular vein with a fistula extending into the peritonsillar abscess — Lemierre's syndrome. ENT took the patient to the OR.   n Lemierre’s syndrome was first described by Andre Lemierre in a 1936 article of 20 cases. This septic thrombophlebitis of the internal jugular vein occurring after an acute pharyngeal infection was often fatal in the pre-antibiotic area. He noted that infection could spread easily to multiple distant sites from the infected vessel, including the lung (most common), brain, liver, and other organs.   n Reports of Lemierre's syndrome have been increasing over the past 15 years or so.   n The infection is most commonly caused by a normally occurring mouth anaerobe called Fusobacterium necrophorum, which produces several toxins including a lipopolysaccharide endotoxin, leukocidin, hemolysin, and hemagglutinin products. Polymicrobial infections have been found in up to a third of patients. (Int J Emerg Med 2013;6[1]:40.)   n The CT shows a distended IJ with enhancing walls, an associated intraluminal filling defect, and soft tissue swelling.   n Treatment is prolonged parental antibiot...
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