Lemierre syndrome associated mycotic cavernous sinus thrombosis and carotid aneurysm after COVID-19

Endogenous endophthalmitis secondary to Lemierre's Syndrome originating from pharyngotonsillitis

PURPOSE

The purpose of this article is to report a case of Lemierre's Syndrome producing unilateral endogenous endophthalmitis in a healthy, young woman with a history of tonsillitis.

CASE REPORT/OBSERVATIONS

A 17-year-old healthy woman developed fever after a few days of sore throat. She later developed pneumonia with septic signs, leading to admission to the Intensive Care Unit. Lemierre Syndrome was diagnosed due to multiple septic pulmonary emboli and signs of sepsis following a recent episode of tonsillitis. During hospitalization, the patient complained of decreased visual acuity and floaters in her left eye. Ophthalmological examination revealed papillary edema, vitritis, foci of chorioretinitis in the macula and Roth's spots, confirming the diagnosis of endogenous endophthalmitis. Subsequently, she underwent appropriate treatment, progressing satisfactorily.

CONCLUSION AND IMPORTANCE

Although ophthalmological manifestations are rare, due to the pathophysiological characteristics of Lemierre's Syndrome, all patients should underwent standard ophthalmologic assessment, even in the absence of ophthalmic symptoms or visible findings, as part of a multidisciplinary management approach.

Concomitant rapidly growing aneurysm of intracavernous carotid artery and cavernous sinus thrombosis: Case report and review of the literature

RATIONALE

Intracavernous infectious aneurysm (ICIA), represents a rare entity that is always described in the form of case reports in the literature. The coexistence of ICIA and cavernous sinus thrombosis (CST) is extremely rare and poorly understood.

PATIENT CONCERNS

A 53-year-old female patient presented to our hospital with headache, nausea and fatigue for 3 weeks. She complained of blurry vision and drooping eyelids before admission. Neurological examination revealed bilateral decreased visual acuity, limitation of extraocular movements and decreased sensation of forehead. Brain magnetic resonance imaging (MRI) showed mixed signal intensities in both cavernous sinuses and expansion of right superior ophthalmic vein, suggesting the formation of CST. One month later, computed tomography angiography (CTA) confirmed a large aneurysm was attached to the left intracavernous carotid artery (ICCA).

DIAGNOESE

This patient was diagnosed with ICIA and CST.

INTERVENTIONS

She was administered with intravenous meropenem and vancomycin and subcutaneous injection of low molecular heparin for 4 weeks.

OUTCOMES

One month later, her extraocular movement had significantly improved, without ptosis and conjunctival congestion. At 1-year follow-up, her ophthalmoplegia fully recovered. Fortunately, such large aneurysm did not rupture in spite of slight broadening.

LESSONS

The coexistence of ICIA and CST is extremely rare. Contiguous infection from adjacent tissues is the foremost cause of ICIA. A repeated angiographic examination is recommended under enough anti-infective treatment due to the characteristics of rapid emergence and fast growth of infectious aneurysms.

Analyzing the relationship between cerebral aneurysms and Non-oculomotor cranial nerve palsies: a systematic review

OBJECTIVES

This study aimed to investigate the association between intracerebral aneurysms and cranial nerve (CN) palsies, focusing on nerves other than the oculomotor nerve. It sought to determine the prevalence, risk factors, and clinical outcomes of these nerve palsies and compare the effectiveness of microsurgical clipping versus endovascular coiling in restoring nerve function.

METHODOLOGY

Following PRISMA guidelines, a comprehensive literature search was conducted using databases like PubMed, Scopus, and Google Scholar, covering studies from 1975 to April 2024. The inclusion criteria targeted patients with non-oculomotor nerve palsies diagnosed with cerebral aneurysms. Studies published before 1975 and non-English studies were excluded. Data extraction included study design, patient characteristics, and intervention outcomes. The Joanna Briggs Institute and Newcastle-Ottawa scales were used to assess study quality. Data were synthesized narratively and statistically analysed using SPSS v27.

RESULTS

The analysis included 47 patients (53.2% female, mean age 44.8 years). The internal carotid artery (ICA) was the most common aneurysm site (44.7%), and the abducent nerve (CN VI) was most frequently affected. Ruptured aneurysms had better recovery outcomes (88.9%) than unruptured ones (66.7%). Hypertension was present in 9.2%. Unilateral aneurysms were seen in 80.9%, with 76.6% having a single nerve palsy. Non-ruptured aneurysms accounted for 58.1%, and ruptured for 41.9% of associated cranial nerve palsies. Treatment included microsurgical approaches (42.6%), endovascular approaches (34%), combined approaches (6.4%), and conservative management (17%). Recovery of the palsy was observed in 75.6%, with endovascular procedures showing higher recovery (93.3%) compared to conservative treatment (28.6%).

CONCLUSION

Intracerebral aneurysms are significantly associated with non-oculomotor CN palsies. Endovascular procedures yield higher recovery rates than conservative management, particularly in ruptured aneurysms. Timely and appropriate treatment is crucial for improving nerve function recovery in these patients.

A Rare and Dangerous Combination of COVID-19, Lemierre Syndrome, and Carotid Pseudoaneurysm: A Case Report

Lemierre syndrome is a rare complication of oropharyngeal infection that causes septic thrombophlebitis in the internal jugular vein. Since the onset of the COVID-19 pandemic, this condition has been dangerously overlooked and poses an even greater threat when complicated by vascular pathologies. A case is presented where the patient required emergency endovascular exclusion of a right internal carotid artery pseudoaneurysm due to Lemierre syndrome. The treatment included stent graft placement and drainage of a neck abscess, along with appropriate antibiotic treatment during hospitalization. Recognizing this diagnosis requires a high index of suspicion, particularly during the COVID-19 pandemic. The complexity of the disease necessitates extensive multidisciplinary collaboration for effective treatment.

Delayed diagnosis of Lemierre's syndrome in a patient with severe coronavirus disease 2019: importance of comprehensive oral and neck examination - a case report

BACKGROUND

Given the widespread prevalence of the coronavirus disease 2019 (COVID-19), oral and neck examinations tend to be avoided in patients with suspected or confirmed COVID-19. This might delay the diagnosis of conditions such as Lemierre's syndrome, which involves symptoms resembling COVID-19-related throat manifestations.

CASE PRESENTATION

A 24-year-old man without any underlying conditions was diagnosed with COVID-19 7 days before presentation. He was admitted to another hospital 1 day before presentation with severe COVID-19 and suspected bacterial pneumonia; accordingly, he was started on treatment with remdesivir and meropenem. Owing to bacteremic complications, the patient was transferred to our hospital for intensive care. On the sixth day, the patient experienced hemoptysis; further, a computed tomography (CT) scan revealed new pulmonary artery pseudoaneurysms. Successful embolization was performed to achieve hemostasis. In blood cultures conducted at the previous hospital, Fusobacterium nucleatum was isolated, suggesting a cervical origin of the infection. A neck CT scan confirmed a peritonsillar abscess and left internal jugular vein thrombus; accordingly, he was diagnosed with Lemierre's syndrome. The treatment was switched to ampicillin/sulbactam, based on the drug susceptibility results. After 6 weeks of treatment, the patient completely recovered without complications.

CONCLUSION

This case highlights the significance of thorough oral and neck examinations in patients with suspected or diagnosed COVID-19 for the detection of throat and neck symptoms caused by other conditions.