Lemierre Syndrome After Tonsillectomy

An 18-year-old woman presented nine days after tonsillectomy with headache, fever and meningeal signs and was admitted to the intensive care unit for suspected meningitis. The usual diagnostic tests for meningitis, according to the current guidelines, were negative. Antibiotics were given. Pulmonary infiltrates were found, and the patient also developed an acute abdomen. Exploratory laparoscopy yielded no abnormal findings. She was intubated because of respiratory instability and shortly thereafter developed acute respiratory distress syndrome, which necessitated treatment with veno-venous extracorporeal membrane oxygenation (vvECMO). Blood cultures were positive for Fusobacterium necrophorum. This Gram-negative anaerobic bacterium is a normal component of the oropharyngeal flora and can cause Lemierre syndrome. A severe disease course with septic emboli and thromboses is typical. The patient was treated, as recommended in the current literature, with a four-week course of antibiotics (meropenem and metronidazole). The vvECMO was removed after seven days of treatment and she was discharged from the hospital after four weeks of treatment with no physical or cognitive deficit. Her good outcome was due in large part to the early taking of blood cultures and the establishment of vvECMO within 24 hours of her respiratory decompensation. This case underscores the fact that hemorrhage is not the only serious complication that can arise after tonsillectomy.

This patient‘s chest x-ray (taken supine) shows evidence of acute respiratory distress syndrome. The vvECMO cannula is seen, along with complete opacification of both lungs with a visible aerobronchopneumogram.