Clinical Vignettes JGIM

CLINICAl. VIGNETTES SEPTIC PULMONARY EMBOLI DUE TO ANAEROBIC PHARYNGEAL Ut~ATERAL GRAVE'SEX~ INFECTION. P.Abtahi. The Reading Hospital and Medical Center, Reading, PA. ~ Adu. D~mmmt ~ lV~eo~ne, Ut~ Vaney ~ ~ LEARNING OBJECTIVES: I. Diagnose of Lemierre syndrome. rmmylv~a CASE: A previously healthy 15 yeas-old female presented to the ER with severe l) Diasn~e sulmeprmatadms efOauve's 13he~ right-sided chest pain and respiratory ~s. One week earlier, she developed a c,ua~ Tm pm~t is a ~-ym,~t ~hbo fma~ tmm~t w ~ h~p~an wi~ ~ sore throat She was evaluated in an outpatient clinic and was started on amoxicillin ~ ,i t,~ a~Kt e~ t~m, ~mms, w~mL mo, mt q~eta~ t~my for pharyngitis. However after her first dose, she experienced a choking sensation vi~m. ~ re~te(llmv~ egpm.im~ a Idewto abe ha) tmpmd amt ~ 3 and stopped taking the antibiotic. One day prior to admission she developed fever woda pt.~to -a-~-~., and has ~ had almd ~T ma gbatwl trodto bu nepe~ve and jaundice with severe right-sided abdominal and chest pain. In the ER she was in for fngtum ~ I~I. le had ao t'" ofvlJn. ~m'us ~ kv~. o..,dld howuv~ have severe respiratory distress, with vital signs I"=36.8, P=I20, RR=35 and BP=I00/60. Her throat was erythematous. The neck exam was benign. Her chest and right upper pineal ~0m tuvml~ e~Id w~hma aed -.,u.,,-e~tho l~ ~ulld and ~ ~ tlasoes abdomen were exquisitely tender to palpation. Arterial hlood gas showed pH=7.42, of~ l~t eye.Thou is ~mmt ef tho l~ ~ bt allplains but no proptu~s. pCO2=32 mmHg, pO2----58mmI-Ig with O 2 saturation 90% on room air. White blood p.mt~ Woed tms as w~ll as ~nid gmg~n and ..~nekl permlda~ mtibod~ cell count was 34,000 with 41% bands and 53% nentrophiis, Hgb-=12.9, platelets wm nennaL A ---,~.,~ t~mo~ imas~g san (MPd) ~ ~,~, =40,000, and her liver function tests were markedly elevated. Chest x-ray revealed sw,4t~ e~ lho ~B~ular m.bltalmugl~ on the le~ and a mlld ~a~..~nmee of two bibasilar atelectssis and a right pleural effusion. Compnted tomograpliy (CT) of the ~U.~___t~_ mugi~ ~n ~he t~ht wi~ q~; e~tho tmdm~ and no evidm~ of maas. chest revealed bilateral septic emboli, a right pleural effitsion and bilateral D~'~JS.~ 1"ao dlf~tlal diagn~s efa p~nt with milamal aophd~ms atelectasis. She was adm/tted to the ICU. After obtalnlnS cultures, metronidazule, vancomycin and gentamicin were started. She subsequently required intubation for respiratory failure and ARDS. She soon required paralysis and sedation due to high pulmonary pressures and di~culty with oxygenation. During the first 24 hours she ~'ne key ovldm~ in lis ca~ ~us gho kW,I gevual~d~lona ef uveral e~raocular was hypoxic with pO2 of 30-40 mmHg on FiO2 of 100% on pressure conUolled nmadl with q~r~g ef tho to~Ik~us k~ons and ahowud no evidmce of x~o- ventilation. She was initially hypotensive as well, requiring three p~ssor agents over the first 72 hours. A neck CT showed inflammation and thrombus in the left ~ bawean ~he d~k~ ead~ ~et~,dme~ t, *e ,t, mco e~/d internal jugular vein with no evidence of an abscess. A right plenrocentesis was ~.~ is due to Ihe/z~lay e¢ mmat lab~,i~ tins to ___ae~___talkie, mhelininsl performed with placement of a chest tube. The fluid was sent for culture and d~m~t~ ~ave's Diem is ~e m~t cmm~ ~nse e~ ~ It is ao analysis. After 48 hours her cnitures were positive for Fusibactenum necrophorum ..t.~,~-je dimrder t, ~d,,leh an abnormal tmmmi0etulta O binds to reoeptera far and Eikenella eorrodens. After penicillin allergy testing, treatment with ampicillin en~/d .emus~ homem t'rs~ on ~he ~ S~Ueabr eem ~ t~ and solbactam was started and the other antibiotics were discontinued. She ,emlaeon ~ d~0id harmme ~ OnM's ~ has 3 msjor defervesced after 20 days of antibiotics at which point she was weaned off the mnifmaem, ~ i.dude teg~em...:a~.~d~y, md dem~hy. ventilator. She was discharged 5 weeks after her initial presentation with no residual Thm mmifmatiem may na ~kt~dU mun~ The qtthalmq~hy may ~ally end organ damage. he anllmral 1)ut _o_a_,,_,bemm~ tilmm.al ev~ tim¢~ Tae ol,Sthmlmepmhy iavoivm an DISCUSSION: Orupbsryngesl infection in healthy adolescents and adults may lead ~mmmy iamu~ ee~e ertim m wah ~ ~ee~e Oebe. ~he inma-~ to an anaerobic sepsis leading to a suppurative thrombophiebitis of the internal i~ pttnn~b, in tt~ m~m~m md tm~'v~ ben~'~ p.-- oek md ekma jugular vein and septic emboli known as Lemierre syndrome. The diagnosis can be wi* ~ h Semi. dini~ manifm~m ia,t~ trem~ weight made based upon the following criteria: I) primary infection in the oropharynx; lm~ ~las. ~ md hnst imetma~ Ocul~ ~ ia¢lude 2) septicemia demonstrated hy at least one positive blood culture for Fusibacterium widmed polpol~ fiasurm, tal-t~ failure to winlde abe brow en UlnVardgsm, lid necrophorura; and 3) evidence of thrombuphlebitis of the internal jugular vein. The has ..a lid reami~ ehme,h. ~ swe~n~ and eonyancevi~ Oa~r disease can be severe but with appropriate antimicrobial therapy and drainage of any complkati~m m iadude mmeal ulcaatiem, el~iC ~ and atmldhy pu.mlent collections, cure can be expected in the majority of patients. DEALING WITH THE UNWANTED TEST. RT Ackcrnmm~ Department of ADDRESSING DOMESTIC VIOLENCE IN PRIMARY CARE. Medicine, UTHSCSA, San Antonio, TX. E Alnert. Boston U. School of Medicine, Boston MA, C Albright, LEARNING OBJECTIVES. Develop a strategy to uppmach results of unwanted tests Stanford U. School of Medicine, Palo Alto CA, H Greene III, CASE. MR is a 93 y/o with deficits of hearing and vision that require her to need Massachusetts Medical Society, Waltham MA. minor help with daily activities. She was admitted from home to the coronmy care unit with one week of dyspnea and l~eductive cough. She had an irregular heart rate at 150, LEARNING OBJECTIVES: 1) Diagnose domestic violence (DV) by crackles at the right lung base, and diffuse wheezing. Mentation was grossly normal. history and clinical manifestations, 2) Assess risk to patient, 3) EKG showed atrial fiin'Ulation with no ischemia. Cardiomegally, mild l~rihilar Approach intervention and safety planning when DV is diagnosed, 4) congestion, a right SI)pl~hilar o~ty, and a right lower lobe infiltrate were seen on Explore strategies for effective communication with at-risk patients. CXR. She receiveddiltiazcm, nebulized beta agnnists, and eml~ic antibiotictherapy CASE: A 32-year-old woman who has been your primary care patient for presumed poeumonia. Her wheezing resolved and heart rate slowed to 80. ~t for about 6 months presents for a scheduled routine health care visit. CXR was unchanged. The radiologist recommended a chest CT to further evaluate. MR was U'an~erred te the Medicine service for a mulignancywork-up. She told Although it is a hot summer day, you notice that she is wearing long me, the Internal Medicine resident, that her wish was to go home without such a work- sleeves. She is also wearing dark sunglasses that she does not remove, up. She understood hew she couldvery well have cancer but feltthat evenifa even though she is inside. Her only complaint is insomnia due to diagnosis were made, she would not want trnslment. Upon exiting her room, my plan "worrying." On exam, BP is 130/94, HR is 90 reg, RR 20. There is a was to dischargeher home the followingmorning, but the radiologist galled with the large fresh ecchymosis around the right eye, and bruises on both resultsof her CT. Uulmown to me, thisscan was porformedimmediately prior to her forearms. Diffuse, faded ecchymoses are noted about the ribs and transfer. Findings confirmed a 2x3cm right hilar mass, with multiple additional ~naller l~lateral no~ales~ 1.5gin subcarianl lymphadenopothy,and multiple liver hypodensities. abdomen:The remainder of the PE is urtremarkable. You frame your This CT dld not s/gnil]cantlyalter my imlxeasion of her likely di~ono~is, yet I was questions carefully and ask about DV. After seeking reassurance that frnstrated with a test that I had not ordered and the i)atient did not warn_ Indoctrinated you will not disclose to her husband what you discuss, the patient under themuntraof"diaom3seandtrent,- I wondered whether I shculd now try to begins to cry and tells you that she has been threatened and beaten convinoeMR to plx)ceedwith furthex work-up. I elected to present the results to her for repeatedly over the last 2 years by her husband. The worst time was six whether our care plan should theirprognnstic value and to discusstogether change. months ago when she sustained two broken ribs and a concussion (a MR understood the test's implications and reiterated her intent to simply go home. Her family welcomed my approach, which also served to help them understand her wishes. colleague of yours treated these injuries but the patient did not report DISCUSSION. As gsneralist clinicians, it is not uncommon that tests are ordered by abuse at that time, nor was she asked). Four days ago, the patient's others that we would not otherwise have requested and that the patiant had simply not husband became angry about a high electric bill, accusing her of desir~ Through this experience, MR has taught me the following: wasting money.

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