Lemierre’s Syndrome: A Rare Case of Pulmonic Valve Vegetation

Lemierre’s syndrome is an uncommon complication of pharyngitis commonly associated with an anaerobic gram negative bacterium, Fusobacterium necrophorum. The syndrome usually affects young healthy adults with the mean age of 20 and is characterized by recent pharyngitis followed by ipsilateral internal jugular vein thrombosis and septic thromboembolism. The treatment is at least 6 weeks of antibiotics; the role of anticoagulation is unclear. The following presentation is a case of Lemierre’s syndrome in a 23-year-old healthy individual who is infected by a rare species: Fusobacterium nucleatum. The case is complicated by septic emboli to the lungs and impressive seeding vegetation to the right ventricular outflow tract (RVOT) at the pulmonic valve of the heart. 1. Introduction A 23-year-old male presented to the emergency room (ER) with a chief complaint of chest pain. The pain was described as midsternal, sharp, graded 8/10, worse with inspiration, associated with shortness of breath, palpitations, and decreased exercise tolerance. Further, he reported viral symptoms including headache, vomiting, fever of 103 Fahrenheit, and night sweats for 7 days prior to ER arrival. Prior to his symptoms, he reports celebrating with friends for several days, including frequent alcohol intake and cigarette smoking. The patient reports a penicillin allergy, with a reaction of “swelling.” His family history is noncontributory. He is a college student. He is a former cigarette smoker; smoking half a pack a day for 5 years and smokes marijuana weekly. He also admits to heavy alcohol use. On physical exam, the patient was normotensive but tachycardic with a heart rate of 120–140 beats per minute. He appeared anxious. There was no jugular venous distention on the neck exam, no bruits, and no lymphadenopathy. His chest was symmetric with poor inspiratory effort and basilar crackles bilaterally. The cardiovascular exam revealed no murmurs, rubs, or gallops. All other system examinations were normal. On admission, laboratory investigations showed a white blood count of 6.8 × 109/L, hemoglobin of 11.4？g/dL, hematocrit of 33%, and platelets of 33 × 109/L. Chest X-ray showed a possible left lower lobe infiltrate. Cardiac enzymes (CEs) and two sets of blood cultures were obtained. Bedside transthoracic echocardiogram showed a severely decreased ejection fraction of 30% with global left ventricular hypokinesis and no right ventricular involvement. Myocarditis was originally suspected. The patient was admitted to the coronary care unit (CCU) and was placed on carvedilol 6.25？mg by