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Lemierre's syndrome - septic thrombophlebitis of the internal jugular vein, usually caused by anaerobic GNR Fusobacterium necrophorum, though can be polymicrobial.  Usually previously well teen with sore throat, strep, mono or other, starts to get better then worsens with unilateral neck pain, tenderness along SCM, looks ill, may have cough with septic emboli to lungs or CNS complications.  Usually do not have big visible cervical adenitis, so you have to suspect it by unilateral pain, tenderness and ill appearance.  Here's a pearl:  if you suspect it, an adult-type set of aerobic and anaerobic blood cultures may be better than the standard peds aerobic BC.  Have seen one!  - Susan Omurathe Children's Hospital at LEgacy EmanuelPortland, OR

> Date: Sun, 23 Jan 2011 20:52:37 -0500
> From: [log in to unmask]
> Subject: Amazing case..did you have one of those?
> To: [log in to unmask]
> 
> A 7 year old Child, recent immigrant from eastern  Europe presented with 4 
> days of right neck swelling.
> He was seen by his PMD 2 days prior had a throat culture which was positive 
>  for strep and discharge on amoxil.
> In our ER he was afebrile, had a very hard slightly erythematous,  tender 
> mass starting behind his right ear, going down his right neck. 
> He also had a stiff neck, holding it straight up. The rest of the exam was  
> normal
> I assumed he had staph/strep lymphadenitis and we debated whether IV Clinda 
>  in the ER with next day follow up is OK or maybe we should admit him.
> We then did an ultrasound which showed multi loculated abscesses, on  
> sitting very close to the right carotid artery.
> Worried about the location of this abscess we did a neck CT (with  
> contrasrt) which confirmed the presence and location of the abscess but  also showed 
> a right internal jugular vein totally clotted from the bifurcation  (with 
> the subclavian) to the level of the angle of C2. The child was  obviously 
> admitted and is being treated (Lemierre's syndrome ?).
>  
> Now, I have seen zillion children with large cervical  lymphadenitis, I do 
> not  use ultrasound on many  ( we had none until a  few years ago...) and 
> certainly do not CT their neck  routinely.
> And now I am asking myself, did I miss those cases  before, was I just 
> lucky that no one ended up septic, I was certainly lucky  here!
> did any one of you have a similar  case?
>  
> Giora Winnik MD
> Maimonides MC, Brooklyn NYC
>  
> 
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For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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                 http://listserv.brown.edu/ped-em-l.html