A Lemierre-like syndrome secondary to forehead furuncle. MSSA bacteremia with cerebral and pulmonary septic embolization

Bavani*

Physician Assistant, Kauvery Hospital, Tirunelveli, Tamil Nadu

*Correspondence

Abstract

A 20-year-old male medical student presented with fever, altered sensorium, severe headache and bilateral orbital edema following a forehead furuncle. CSF showed a lymphocytic-predominant inflammatory picture, while MRI brain demonstrated multifocal infarcts and meningeal enhancement. He rapidly deteriorated, requiring intubation and mechanical ventilation. MRI orbit showed bilateral orbital cellulitis and venous thrombosis. CT chest revealed peripheral cavitating nodules suggestive of septic emboli. Culture of the forehead furuncle grew Staphylococcus aureus, and blood culture grew methicillin-sensitive Staphylococcus aureus (MSSA). Imaging demonstrated internal jugular vein thrombosis. The patient was treated with targeted anti-staphylococcal antibiotics, anticoagulation and intensive supportive care, with gradual neurological and respiratory recovery. This case represents a Lemierre-like syndrome arising from a facial skin infection rather than the usual oropharyngeal source.

Keywords: Lemierre-like syndrome; MSSA bacteremia; Forehead furuncle; Orbital cellulitis; Internal jugular vein thrombosis; Septic emboli; Cerebral infarction

Introduction

Lemierre syndrome classically involves an oropharyngeal infection followed by internal jugular vein thrombosis and septic embolization. This case highlights a similar septic thrombophlebitis pathway originating from a forehead furuncle, with involvement of the orbit, brain and lungs.

Case Presentation

A 20-year-old male, first-year MBBS student, developed a forehead pimple followed by eyelid swelling, severe headache and fever. He was initially treated elsewhere and later developed altered sensorium with worsening consciousness. On admission, he was febrile, drowsy but arousable, with neck stiffness, bilateral orbital/conjunctival edema (right greater than left) and a forehead furuncle.

Investigations

CSF was turbid with protein 225 mg/dL, glucose 62 mg/dL and 990 cells/mm3 with lymphocytic predominance. Gram, fungal and parasitic studies were negative, and CSF culture showed no growth. MRI brain showed multifocal acute infarcts involving the right medial temporal lobe, pons, medulla and cerebellar peduncles with meningeal enhancement. MRI orbit showed bilateral orbital cellulitis and right supraorbital venous thrombosis. CT chest showed peripheral cavitating nodules consistent with septic emboli. The forehead pus culture grew S. aureus, and blood culture grew MSSA. CT venography demonstrated internal jugular vein thrombosis. TEE showed no vegetation.

Treatment and Clinical Course

Empirical meropenem, vancomycin and acyclovir were started initially. The patient deteriorated rapidly with severe reduction in GCS, shallow breathing and desaturation, requiring intubation and mechanical ventilation. Following MSSA isolation, treatment was shifted to flucloxacillin with continued supportive management. Therapeutic anticoagulation was started for internal jugular vein thrombosis. He also received neuroprotective measures and ophthalmology management for orbital cellulitis. During recovery, he developed hospital-acquired airway infection, which was treated appropriately. Renal dysfunction is resolved with supportive care.

Outcome

Neurological status gradually improved and fever subsided. He was weaned from mechanical ventilation to BIPAP and then room air. Tracheostomy was performed for prolonged airway support and was later successfully decannulated after satisfactory bronchoscopy and swallowing assessment. He was mobilized, tolerated oral feeds and was discharged in stable condition with follow-up planned.

Discussion

The combination of a forehead furuncle, MSSA bacteremia, orbital cellulitis, internal jugular vein thrombosis, multifocal cerebral infarcts and cavitating pulmonary nodules supports a Lemierre-like septic thrombophlebitis syndrome. Unlike classical Lemierre syndrome, the primary source of this patient was a facial skin infection. Early recognition of the source and multidisciplinary treatment were important for recovery.

Conclusion

A facial furuncle can rarely lead to severe systemic infection with septic thrombophlebitis and embolization. In patients with fever, orbital swelling and neurological deterioration, a head-and-neck source should be actively evaluated. Lemierre-like syndrome should be considered even when the primary infection is not pharyngeal.

Learning Points

  • Do not overlook facial furuncles as a potential source of serious infection.
  • Orbital cellulitis with fever and neurological symptoms requires urgent evaluation.
  • MSSA bacteremia with internal jugular thrombosis can produce a Lemierre-like clinical picture.
  • Negative TEE does not by itself exclude septic thrombophlebitis or septic embolization.
  • Early antimicrobial therapy, anticoagulation when indicated, source evaluation and multidisciplinary care can support recovery.

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