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    Child’s ear pain progresses to leg pain, arm pain, and fever

     

    Patient outcome

    Because the patient continued to complain of intermittent left elbow pain, she had an MRI of her elbow, which showed a small-to-moderate joint effusion. A CT-guided arthrocentesis of her left elbow was done, and the fluid suggested a septic arthritis. She underwent an incision and drainage of the elbow. She was transferred to a long-term assisted care hospital for prolonged antibiotics.

    The patient continued on IV ampicillin/sulbactam for a total of 8 weeks when a brain and neck MRI was repeated, which showed further inferior extension of the right sigmoid and internal jugular vein thrombosis but decreased inflammation. Intravenous antibiotics were continued for another 2 weeks, then switched to oral amoxicillin/clavulanic acid for an additional 2 months.

    Next: Girl's papular rash will not respond to treatment

    Antibiotics were discontinued once the patient had a normal exam and normal inflammatory markers. Enoxaparin was continued for a total of 5 months and was stopped because of loss of insurance. The patient was lost to follow-up because of a change in insurance.

    Summary

    Prior to the antibiotic era, such as when Lemierre described this disease process in 1936, this syndrome was almost always fatal. Now with advanced imaging modalities, IV antibiotics, and surgical subspecialists, most patients recover. However, morbidity remains high, usually because there is delay in diagnosis and septic emboli have occurred.4

    Whereas this illness was originally described as a complication of pharyngitis because of Fusobacterium in adolescents and young adults, LS can be seen as a complication of mastoiditis attributed to S pyogenes in children. Therefore, primary care pediatricians should be aware of this rare complication of otitis media.

    REFERENCES

    1. Arnold JC, Bradley JS. Osteoarticular infections in children. Infect Dis Clin North Am. 2015;29(3);557-574.

    2. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am.1999;81(12):1662-1670.

    3. Tumeh SS, Aliabadi P, Weissman BN, McNeil BJ. Disease activity in osteomyelitis: role of radiography. Radiology. 1987;165(3):781-784.

    4. Baig MA, Rasheed J, Subkowitz D, Vieira J. A review of Lemierre syndrome. Internet J Infect Dis.2005;5(2).

    5. Ridgeway JM, Parikh DA, Wright R, et al. Lemierre syndrome: a pediatric case series and review of literature. Am J Otolaryngol. 2010;31(1):38-45.

    6. Stokroos RJ, Manni JJ, de Kruijk JR, Soudijn ER. Lemierre syndrome and acute mastoiditis. Arch Otolaryngol Head Neck Surg. 1999;125(5):589-591.

    7. Goldenberg NA, Knapp-Clevenger R, Hays T, Manco-Johnson MJ. Lemierre’s and Lemierre’s-like syndromes in children: survival and thromboembolic outcomes. Pediatrics. 2005;116(4):e543-e548.

    8. Aspesberro F, Siebler T, Van Nieuwenhuyse JP, Panosetti E, Berthet F. Lemierre syndrome in a 5-month-old male infant: case report and review of the pediatric literature. Pediatr Crit Care Med. 2008;9(5):e35-e37.

    9. Harris CM, Johnikin M, Rhodes H, et al. Lemierre’s syndrome resulting from streptococcal induced otitis media and mastoiditis: a case report. J Med Case Rep. 2009;3:6658.

    10. Chirinos JA, Lichtstein DM, Garcia J, Tamariz LJ. The evolution of Lemierre syndrome: report of 2 cases and review of the literature. Medicine (Baltimore). 2002;81(6):458-465.

    11. Wilson P, Tierney L. Lemierre syndrome caused by Streptococcus pyogenes. Clin Infect Dis. 2005;41(8):1208-1209.

    12. Anton E. Lemierre syndrome caused by Streptococcus pyogenes in an elderly man. Lancet Infect Dis. 2007;7(3):233.

    13. Blumberg D, Brazzola P, Foglia CF, Fiore E, Bianchetti MG. Lemierre syndrome caused by group A Streptococci. Pediatr Infect Dis J. 2007;26(7):661-662.

    14. Shah RK, Wofford MM, West TG, Shetty AK. Lemierre syndrome associated with group A streptococcal infection. Am J Emerg Med. 2010;28(5):643.e5-643.e8.

    15. Frizzola MA, Hertzog JH. Lemierre syndrome in a 22-month-old due to Streptococcus pyogenes. Pediatr Emerg Care. 2011;27(11):1078-1080.


    Holly D Smith, MD
    Dr Smith is an assistant professor in the Department of Pediatrics, McGovern Medical School, Houston, Texas.
    Peter T Scully, MD
    Dr Scully is a second-year pediatric critical care fellow in the Department of Pediatrics, McGovern Medical School, Houston.

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