Presentation
One week of worsening and painful neck swelling. Septic on presentation with WCC 28 and CRP 300. No background medical issues.
Patient Data
Large left neck collection measuring over 9 cm in the longest dimension, extending from the level to C2 to T1. Thickened irregularly enhancing wall with central fluid / necrosis, and some foci of gas centrally within this (no history of percutaneous aspiration).
The airway is displaced to the right, with edema of the left palatine tonsil and supraglottic structures.
Extensive surrounding fat reticulation, with small volume unencapsulated fluid in the retropharyngeal space. The sternocleidomastoid muscle is inseparable from the lateral neck mass, with the submandibular gland displaced anteriorly and the carotid vessels displaced medially. Reactive local nodal enlargement.
Although the left transverse and sigmoid dural venous sinuses are patent, the left internal jugular vein is not opacified in the neck and considered occluded if not thrombosed by the lateral neck mass.
Normal included intracranial structures. Normal included skeleton. Soft tissue stranding continues into the imaged mediastinum (chest imaged separately with no acute findings).
Interval surgical drainage, with insertion of corrugated neck drain. Reduced size of the abscess, particularly in the axial plane. Defined collection within the belly of sternocleidomastoid.
Resolved airway edema.
Similar appearance of the left internal jugular vein with compression / occlusion level with the abscess. No intracranial venous or other abnormality.
Case Discussion
A large acute neck collection with internal jugular venous occlusion / thrombus in a previously healthy young patient.
Septic thrombophlebitis in neck infections is typically described as Lemierre syndrome - although the triad for this condition is completed by embolic disease (usually pulmonary deposits although endocarditis, septic arthritis and meningitis are also recognized) which was not present in this case.
However surgical drainage of the abscess did yield large numbers of Fusobacterium necrophorum which is the anaerobic organism which is classically associated with Lemierre syndrome. This Gram negative bacteria is part of the normal flora of the aerodigestive tract and is considered to result in these infections as a secondary response to mucosal disturbance in pharyngitis from other bacterial or viral causes.
Unable to process the form. Check for errors and try again.