Bilateral intraocular involvement in Lemierre's syndrome

First described in 1936, Lemierre's syndrome is an oropharyngeal infection characterised by septic thrombophlebitis of head and neck veins, complicated by dissemination of septic emboli to pulmonary and systemic sites.¹ Ophthalmic involvement in this syndrome is extremely uncommon, having been reported previously in a patient with retro‐orbital involvement and proptosis,² and more recently as a case of endogenous endophthalmitis.³ Here, we describe a case of bilateral intraocular involvement in this interesting and rare disease.

Case report

A previously healthy 14 year old African American female presented to the emergency department with cough, dyspnoea and tachypnoea, and a pulse oximeter reading of 70% on room air. A chest x ray demonstrated diffuse bilateral pulmonary infiltrates and a right sided pleural effusion. Empirical treatment with intravenous vancomycin 1 g intravenously every 12 hours and cefotaxime 1 g intravenously every 8 hours was initiated. She was transferred to the intensive care unit for treatment and further examination. Her laboratory studies were remarkable for a rapid decline in her haemoglobin from 12.6 g/dl to 8.6 g/dl and a drop in platelet count from 57 000×10⁹/l to 35 000×10⁹/l.

Computed tomography (CT) of the neck revealed a left parapharyngeal abscess adjacent to a clot in the left internal jugular vein (fig 1). Multiple other lesions, thought to be septic emboli, were found systemically, including in her liver, spleen, and lungs. Subsequent blood cultures were positive for Fusobacterium necrophorum. Her antibiotic regimen was changed to clindamycin 300 mg intravenously every 6 hours.

Figure 1 Computed tomography (CT) scan with intravenous contrast of the neck at the level of the hyoid bone. Note the patency of the carotid arteries bilaterally (black arrowheads). On the right, the internal jugular vein is patent (white arrow), whereas on the left the internal jugular vein is thrombosed (black arrow).

Initial ophthalmic examination was significant for visual acuity of light perception in the right eye and 20/150 in the left with normal pupillary responses, intraocular pressure, and anterior segments. Indirect ophthalmoscopy revealed a dense vitreous haemorrhage in the right eye, precluding any view of the retina, and a preretinal haemorrhage in the left eye centred over the macula. B‐scan ultrasonography of the right eye demonstrated vitreous haemorrhage and a subretinal mass with moderate internal reflectivity (fig 2). Three weeks after her initial presentation, her platelet count normalised and blood cultures were negative, but the dense vitreous haemorrhage is the right eye persisted with light perception vision. Subsequently, a pars plana vitrectomy was performed on the right eye, from which Gram stains and cultures were negative. Intraoperatively, the subretinal mass appeared to be an organised abscess with breakthrough vitreous haemorrhage.

Figure 2 B‐scan ultrasound of the right eye demonstrates a subretinal mass of moderate internal reflectivity (white arrows) accompanied by vitreous haemorrhage.

At the 2 month visit, her vision improved to 20/80 in the right eye and 20/25 in the left eye.

Comment

Lemierre's syndrome is a rare and potentially fatal medical emergency characterised by an anaerobic oropharyngeal infection leading to septic thrombophlebitis of the internal jugular vein, often complicated by distant metastatic infections. The majority of reported cases have occurred in previously healthy young adults, and Fusobacterium necrophorum is the usual aetiological agent. In the post‐antibiotic era, the clinical signs are typically pharyngitis, a tender and swollen neck, and non‐cavitating pulmonary infiltrates.⁴

Ophthalmic complications of Lemierre's syndrome have rarely been reported in the literature and include proptosis and endophthalmitis. Bilateral intraocular involvement is exceedingly uncommon.