Bilateral gluteal abscesses as a unique manifestation of Fusobacterium septicaemia

M. C. Pickering, T. Barkham1, J. C. Mason, S. Shaunak1 and K. A. Davies2

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 0–10), erythrocyte sedimentation rate of 90 mm in the first hour (normal range 0–10), haemoglobin 10.5 g/dl (normal range 11.5–14.9), white cell count 31.6 x 109/l (normal range 3.2–11), neutrophil count 28.6 (normal range 1.9–7.7) and creatinine phosphokinase 75 IU/l (normal range 0–170). 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. 1Go).



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Fig. 1. CT section through the gluteal region showing bilateral focal areas of low attenuation involving both gluteal maximus muscles (arrows). These appearances are consistent with bilateral gluteal muscle abscesses.

 
Four hours after admission she developed a pyrexia of 40°C. Broad spectrum antibiotic therapy with intravenous cefotaxime and metronidazole was started. Blood and urine cultures remained negative. Despite antibiotic therapy she remained pyrexial and 3 days after admission 80 ml of foul-smelling purulent fluid was aspirated from the left sided abscess. No organisms were seen on microscopy. The following day percutaneous drains were inserted into both gluteal abscesses. One hundred millilitres of pus was drained from the right sided abscess and a further 30 ml from the left sided abscess. No further drainage occurred despite 6 hourly irrigation of both drains with sterile saline. Her haemoglobin had fallen to 7.4 g/dl and her pyrexia persisted. Streptokinase solution (streptokinase 125 000 units in 20 ml of sterile saline) was then injected into each drain daily and she received a 3-unit blood transfusion. A further 200 ml of fluid drained from each buttock over the next 48 h and her clinical condition rapidly improved. Over the following 6 days she became apyrexial and her white cell count and acute phase response returned to normal. GLC analysis of the aspirated pus demonstrated a volatile fatty acid profile characteristic of Fusobacterium species. Prolonged culture of the gluteal aspirates failed to grow any organisms although the cultures were taken after antibiotic treatment was well established. However, despite the negative cultures, the GLC result supported the clinical diagnosis of Fusobacterium septicaemia. After a further week in hospital receiving physiotherapy she was mobilizing independently and was discharged after an in-patient stay of 3 weeks.

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 Epstein–Barr 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. Back

References

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  4. Dagan R, Powell KR. Postanginal sepsis following infectious mononucleosis. Arch Intern Med 1987;147:1581–3.[Abstract]
  5. Wolf RFE, Konings JG, Prins TR, Weits J. Fusobacterium pyomyositis of the shoulder after tonsillitis. Acta Orthop Scand 1991;62:595–6.[ISI][Medline]
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  9. Chin NK, Lim TK. Controlled trial of intrapleural streptokinase in the treatment of pleural empyema and complicated parapneumonic effusions. Chest 1997;111:275–9.[Abstract/Free Full Text]
Accepted 8 September 1999





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