WIDI - CA0126-Pharyngitis with Lemierre, CT

CA0126-Pharyngitis with Lemierre, CT

History

25-year-old male with severe throat pain and fever in the emergency room being evaluated for a possible retropharyngeal abscess.

Exam

Contrast-enhanced CT of the maxillofacial region and neck and related anatomy with images obtained in the balanced or venous vascular phase to ensure optimal visualization of both arterial and venous structures as well as possible reactive changes around infected collections. 0.5-3.0 mm thick sections were obtained in the axial plane and reformatted 3D and/or in the coronal and sagittal planes and viewed inter actively in 3 dimensions at the computer work station.

Prior Study

None

Findings

General

There is no general or localized soft tissue swelling of the superficial or deep neck soft tissues.

Nasopharynx Including Retropharyngeal Lymph Nodes

There is hypertrophy and inflammation of the adenoids and very extensive edema within the fat of the adjacent parapharyngeal and retropharyngeal spaces.

Oropharynx

There is extensive hypertrophy and inflammation of the palatine tonsils which encroach minimally on the oropharyngeal airway. There is no evidence of tonsillar abscess. There is associated very marked edema within the fat of the adjacent retropharyngeal and parapharyngeal spaces.

Retropharyngeal Lymph Nodes

There are bilateral reactive retropharyngeal lymph nodes. There is a suppurative left retropharyngeal node. That node measures under 2 cm in size in its maximum short axis dimension. The presumed purulent material is confined to the node.

Vascular Findings

There is thrombosis of the left jugular vein from just below the skull base to its junction with the common facial vein and this finding raises a strong possibility of Lemierre syndrome.

The remainder of the visceral compartment of the head neck region and deep neck structures as well as the spine are within normal limits for the patient’s age.

Upper Lung Zones and Mediastinum

The upper lung zones and mediastinum visualized are normal.

Impression

Pharyngitis with suppurative lymphadenitis without abscess but complicated by jugular thrombosis and possible Lemierre syndrome.

Recommendations

There was immediate verbal communication of these findings to the emergency medical service and follow-up communication with the otolaryngology service with regard to this matter. Based on the findings the otolaryngology service managed the situation with intravenous antibiotics and the medical service was consulted to help manage risk of Lemierre syndrome.

Acuity

Non routine communication is required if findings suspicious for unusually aggressive abscess, vascular complications (such as the Lemierre syndrome) or significant airway narrowing due to pharyngeal, deep neck or spine and epidural infection are noted.

Non routine communication was considered necessary in this matter due to the risk of possible development of Lemierre syndrome systemic manifestations.