1 Rheumatology Section, Division of Medicine, Department of Infectious Diseases, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
Sir, Human infection with Fusobacterium necrophorum produces a condition known as Lemierre's syndrome, post-anginal sepsis or necrobacillosis [1]. Typically patients complain of a severe sore throat and subsequently develop a septicaemic illness with abscesses occurring predominantly in the lungs and joints. We describe the case of a previously healthy 21-yr-old Caucasian female who, following a sore throat, developed septicaemia and bilateral gluteal abscesses. The diagnosis of Fusobacterium septicaemia was supported by the clinical presentation and the gas liquid chromatography (GLC) profile of the gluteal aspirates. The development of bilateral gluteal abscesses as the predominant metastatic manifestation of Fusobacterium septicaemia has not previously been reported.
A 21-yr-old Caucasian waitress developed a sore throat associated with pain on swallowing. The following day she developed pain in both buttocks. Her General Practitioner prescribed a course of erythromycin. After 10 days her sore throat had completely resolved but the pain in her buttocks had become intense. There was no history of fevers, rigors or night sweats. She was previously fit and well, but was due to travel abroad and had received hepatitis B, typhoid and rabies vaccinations during the preceding month, all of which had been administered into her left deltoid. She was not on any regular medication except for the recent course of erythromycin. There was a well-documented history of penicillin allergy. The patient was a non-smoker and denied taking any illicit drugs. On examination she was apyrexial and was in obvious discomfort from the pain in her buttocks. Ear and throat examination was normal and there was no lymphadenopathy. Cardiovascular, respiratory and abdominal examination including rectal and vaginal examinations were normal. She had marked tenderness to palpation over both buttocks and the lateral aspect of her hips. There were no overlying skin changes.
Investigations showed a C-reactive protein of 197 mg/l (normal range 010), erythrocyte sedimentation rate of 90 mm in the first hour (normal range 010), haemoglobin 10.5 g/dl (normal range 11.514.9), white cell count 31.6 x 109/l (normal range 3.211), neutrophil count 28.6 (normal range 1.97.7) and creatinine phosphokinase 75 IU/l (normal range 0170). Serum electrolytes, renal function, liver function tests and random blood glucose were normal. No pathogens were isolated from a throat swab and blood and urine cultures. A chest radiograph was normal. An ultrasound of her abdomen, pelvis and hips was normal. However, the ultrasound appearances of both gluteal regions and the lateral aspect of both thighs were abnormal. A non-enhanced computed tomography (CT) scan of the gluteal regions and upper thighs showed evidence of bilateral gluteal abscess formation (Fig. 1).
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Fusobacteria are long, thin, non-spore forming Gram-negative anaerobic bacilli and are normal commensals of the human oropharynx. In 1936 Lemierre described the clinical manifestations of infection due to F. necrophorum, which he termed post-anginal septicaemia [2]. Consistent with Lemierre's original description, an analysis of 45 cases by Eykyn showed that the commonest clinical presentation was the development of a sore throat in previously fit, healthy young adults, followed by rigors and the formation of abscesses predominantly in the lungs [3]. Metastatic abscesses did occur at other sites including the knee joint, hip joint, liver and submandibular gland, but there was no report of muscle involvement. The pathophysiology of this disease begins with infection in the lateral pharyngeal space. A septic thrombophlebitis of the tonsillar veins, often extending to involve the internal jugular vein, develops and septic thrombosis in the affected veins then acts as a source of septic emboli [1]. Why the organism, a normal commensal of the oropharynx, becomes invasive is not known. An association between infectious mononucleosis and Fusobacterium infection has been proposed [4] but in our case there was no serological evidence of acute EpsteinBarr virus infection.
Fusobacterium infection has previously been documented as a cause of pyomyositis in only a small number of case reports. Wolf et al. described a 19-yr-old male who, 4 weeks after developing a severe sore throat, presented with a Fusobacterium pyomyositis affecting the left infraspinatus muscle [5]. Fusobacterium nucleatum was isolated from the left quadriceps muscle in a case of pyomyositis affecting a 34-yr-old man who also gave a history of recurrent throat infections [6].
Fusobacteria are sensitive to many antibiotics in vitro including penicillin, metronidazole and clindamycin [3, 7]. Both metronidazole and clindamycin, used alone, have been reported as effective therapy [1, 3, 7]. However, although variable in vitro sensitivity is reported, erythromycin is not a reliable agent for treating infections caused by fusobacteria [8]. Early antibiotic treatment is important since delayed therapy is associated with a higher mortality [3]. The case reported here illustrates the value of streptokinase in facilitating percutaneous drainage of soft tissue collections. Intrapleural streptokinase in the treatment of empyemas is effective and increases the volume of fluid drained from pleural collections [9]. The facilitation of drainage using streptokinase in this case accelerated recovery and avoided a formal surgical drainage procedure which would have lengthened the patient's hospital stay and possibly increased morbidity.
This report illustrates the serious nature of Fusobacterium infection and highlights a previously unreported manifestation of Fusobacterium septicaemia. Although necrobacillosis is an uncommon condition it should be suspected in healthy adults who develop a septicaemic illness with abscess formation following a sore throat.
Acknowledgments
We are grateful to the Anaerobic Reference Laboratory, University Hospital of Wales, Cardiff for the GLC profile of the aspirated pus.
Notes
2 Correspondence to: K. Davies.
References