Title : Unilateral ptosis, proptosis and limb weakness - Unusual signs of a rare complication; Lemierre’s syndrome – A case report
Abstract:
Lemierre's syndrome, thrombophlebitis of the Internal Jugular Vein (IJV) with secondary sepsis and infective metastatic lesions, is a rare complication typically of anaerobic bacterial infection of the oropharynx, occurring predominately in the younger adult population. About half the reported cases, termed variants, do not fit the classical definition and can pose diagnostic difficulties.
This case report is of a 63-year-old man who presented to the Emergency Department with a 24-hour history of worsening confusion and a fever. His only significant medical history was of an iron deficiency anaemia currently under investigation and a recent blood transfusion. Initial management focused on resuscitation for a sepsis secondary to a pneumonia confirmed on imaging. Approximately 10 hours later, when clinically stable and with the delirium settled, a history of headaches, left neck pain, recent left ptosis, diplopia and mild left sided weakness, confirmed on examination, was established. Also evident was a new left proptosis with worsening chemosis and conjunctival injection. The possibilities of a right MCA territory stroke, carotid artery dissection and orbital cellulitis were raised. Blood cultures taken on admission grew a Streptococcus sp. in both bottles.
A CT head showed no established infarct. An urgent ophthalmology review confirmed a partial 3rd nerve palsy and raised the possibility of Orbital Apex Syndrome while an urgent MRI head showed Superior Ophthalmic Vein thrombosis bilaterally - worse on the left - and probable transverse and sigmoid sinus thrombosis.
Subsequent targeted imaging confirmed extensive sinus thrombosis extending to the left IJV, a large organized non-occlusive thrombus in the left IJV and left cervical paravertebral collections, all leading to a definitive diagnosis. The organism cultured was of the Streptococcus milleri group.
Diagnosis here passed through various stages on account of several factors: the condition's atypical presentation, its evolution during admission, and the patient's age demographic. Further imaging showed no other organ involvement and no underlying malignancy. The symptoms of diplopia and weakness resolved with treatment.
