COVID-19 News: Physicians From Texas Tech Warn That SARS-CoV-2 Infections Can Give Rise To Lemierre’s Syndrome!

COVID-19 News: Physicians from Texas Tech University Health Sciences Center-USA, Nassau University Medical Center-USA, Mamata Medical College-India, People's Education Society Institute of Medical Sciences and Research (PESIMSR)-India and University of Louisville-USA are warning that SARS-CoV-2 Infections can give rise to Lemierre’s Syndrome in certain individuals after themselves reporting such a case study.


 
Lemierre’s syndrome is a condition when an oropharyngeal infection, typically from Fusobacterium necrophorum, causes thrombophlebitis of the internal jugular vein. It is characterized as a condition of inflammation of the wall of the internal jugular vein and infected thrombus in the lumen caused by an oropharyngeal infection with surrounding soft tissue swelling and inflammation
 
Fusobacterium necrophorum is often found in the throat without causing infections. It's possible that this syndrome happens when the bacteria get into the mucus membranes around the throat. The condition can be fatal.
 
Patients with Lemierre’s syndrome present initially with fever, sore throat, exudative pharyngitis, and/or peritonsillar abscess. The symptoms persist, severe neck pain and swelling develop, and the patient appears toxic. Septic shock may ensue along with metastatic complications, especially septic pulmonary emboli.
 
To date, there has been rising cases of Lemierre's syndrome where COVID-19 infection is the prime suspect for causing this syndrome but there has been no COVID-19 News coverages about these cases so far.
 
SARS-CoV-2 infection, known to cause hypercoagulability and immunosuppression, increases the risk of deep venous thrombosis and secondary infections.
 
The study team comprising the physicians from Texas Tech University Health Sciences Center reported a case of a young male with no known risk factors who developed Lemierre’s syndrome as a complication of COVID infection.
 
The 31-year-old male with no significant medical history and no intravenous (IV) drug abuse was transferred to their facility for evaluation of left-sided neck pain and swelling. The patient had a fever and upper respiratory infection (URI) a week ago before developing neck pain and swelling. At admission, his vitals were temp 100.4°F, heart rate 116 bpm, blood pressure 120/81 mm Hg, and SpO2 94% on room air. His physical exam was only significant for tenderness of the left side of the neck and engorged veins with swelling.
 
Blood diagnostic results showed significant for leukocytosis ie 17.6 x 103/μL with neutrophilia at 76% and lymphopenia at 14.7%, and the C-reactive protein was 16.3 mg/dL. Another significant finding was that his A1c was > 14.0%. A drug screen was negative, and other labs including electrolyte panels and cultures were unimpressive.
 
CT or computed tomography of the neck confirmed an occluded left EJV with a thrombus extending into the left subclavian vein, brachiocephalic vein, and the superior mediastinum with patchy bilateral airspace opacities consistent with multilobar pneumonitis.
 
CT angiography of the chest showed the presence of bilateral septic emb oli.
 
A subsequent duplex ultrasound confirmed an acute thrombus of the left subclavian vein. A 2D echocardiogram showed an ejection fraction of >60%, with no signs of endocarditis.
 
The infected patient was started on treatment for septic thrombophlebitis. His SARS-CoV-2 polymerase chain reaction study was negative, but antibodies were positive for IgG with quantitative IgG of 58.0 BAU/mL, establishing recent COVID-19 infection, given his upper respiratory infection (URI) symptoms a week prior.
 
Surprisingly, all his cultures remained negative, likely because of the early initiation of antibiotics before the samples were drawn. He was initially treated with linezolid, piperacillin + tazobactam, and clindamycin with no significant improvement.
 
It was reported that his hospital stay was complicated with parotitis and a lack of clinical improvement, necessitating escalation of antibiotics to meropenem and continuation on linezolid.
 
The patient showed significant improvement in clinical status with a reduction in his parotid swelling and induration on the left face and neck. The physicians discharged the patient on apixaban and ertapenem for four weeks, with a follow-up appointment.
 
The case report was published in the journal: Cureus.
https://www.cureus.com/articles/135529-lemierres-syndrome-in-the-external-jugular-vein-precipitated-by-covid-19-infection#!/
 
The proposed mechanism by which oropharyngeal organisms cause septic thrombophlebitis is postulated to be via hematogenous spread through a tonsillar vein or lymphatics. The involvement of EJV (external jugular vein) thrombophlebitis has been reported to be caused by alpha-hemolytic streptococci in multiple case reports.
 
This reported case presents a unique scenario of recent COVID-19 infection directly causing or provoking septic thrombophlebitis uniquely in the EJV.
 
Infection with SARS-CoV-2 is known to cause a prothrombotic state from endothelial injury and changes in circulating prothrombotic factors like elevated factor VIII, fibrinogen, neutrophil extracellular traps, and hyperviscosity.
 
Common clinical manifestation includes fever, sore throat, dysphagia, unilateral neck pain, and tenderness. Most patients have prior parotitis or an upper airway infection. The patient presented with left-sided neck pain, swelling, and tenderness that started after an upper respiratory infection a week prior, which is presumed to be a COVID-19 infection due to his high antibody titers. The thrombus can embolize, cause septic emboli in the lungs, and present as dyspnea, pleurisy, or sometimes with hemoptysis.
 
Typical Lemierre's syndrome usually involves IJV, and EJV involvement is rare with only a few cases reported in the literature. The patient likely had a recent COVID-19 infection with negative PCR and positive antibodies. This forgotten and life-threatening condition was likely triggered in this patient by a recent SARS-CoV-2 infection and uncontrolled diabetes.
 
Prompt diagnosis and initiation of appropriate antibiotics remain the mainstay of treatment.
 
Physicians should be very diligent about when to use anticoagulation, especially in cases with progressive thrombosis and septic emboli.
 
Lemierre's syndrome caused by bacteria is well-known and has been reported in many cases, but this is the first case of COVID-19-precipitated Lemierre's syndrome that also presented in the EJV.
 
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