Lemierre's syndrome and 2016 American College of Physician guidelines for pharyngitis: no to empiric coverage for bacterial pharyngitis. While no role for routine Fusobacterium PCR, keep suspicion for this pathogen

BMJ Case Reports
Michael Saul LundinHeather Laird-Fick

Abstract

An 18-year-old woman presented to clinic with acute pharyngitis with 4/4 Centor criteria. Rapid streptococcal antigen test was negative. The patient, who was allergic to penicillin, was prescribed azithromycin. Ultimately, after 5 days and without any corticosteroids, she presented to the emergency department with 10/10 chest pain and was admitted to the intensive care unit. CT showed nodular lung disease and blood cultures on admission grew Fusobacterium, likely Fusobacterium nucleatum. She sustained two cardiac arrests, three tube thoracostomies, acute kidney injury requiring dialysis and ventilatory failure requiring tracheostomy. After 16 days in hospital and 18 days in long-term acute care, the patient was discharged home. It is unclear how much of this could have been prevented by prescribing an antimicrobial that had activity against Fusobacterium When severe pharyngitis occurs, Fusobacterium needs to be considered as an underlying cause. In vitro macrolides have marginal activity against most anaerobes, such as this pathogen, and should be avoided.

References

Apr 4, 2007·Clinical Microbiology and Infection : the Official Publication of the European Society of Clinical Microbiology and Infectious Diseases·A JensenJ Prag
Mar 12, 2008·European Journal of Clinical Microbiology & Infectious Diseases : Official Publication of the European Society of Clinical Microbiology·L Hagelskjaer Kristensen, J Prag
Dec 2, 2009·Annals of Internal Medicine·Robert M Centor
Mar 20, 2014·The Journal of Infection·Chloe Eaton, Jonathan Swindells
Jan 20, 2016·Annals of Internal Medicine·Aaron M HarrisUNKNOWN High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention

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Citations

Feb 19, 2019·Clinical Practice and Cases in Emergency Medicine·Akshay K ElagandhalaHenry E Wang

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