Clival osteomyelitis and hypoglossal nerve palsy—rare complications of Lemierre's syndrome

Abstract

An increasingly reported entity, Lemierre's syndrome classically presents with a recent oropharyngeal infection, internal jugular vein thrombosis and the presence of anaerobic organisms such asFusobacterium necrophorum. The authors report a normally fit and well 17-year-old boy who presented with severe sepsis following a 5-day history of a sore throat, myalgia and neck stiffness requiring intensive care admission. Blood cultures grewF. necrophorumand radiological investigations demonstrated left internal jugular vein, cavernous sinus and sigmoid sinus thrombus, left vertebral artery dissection and thrombus within the left internal carotid artery. Imaging also revealed two areas of acute ischaemia in the brain, consistent with septic emboli, skull base (clival) osteomyelitis and an extensive epidural abscess. The patient improved on meropenem and metronidazole and was warfarinised for his cavernous sinus thrombosis. He has an on-going left-sided hypoglossal (XIIth) nerve palsy.

A comprehensive review of skull base osteomyelitis: Diagnostic and therapeutic challenges among various presentations

“…Some case studies have reported a link between clival osteomyelitis and different pathogens, such as Enterococcus faecium and MRSA, and an anaerobe, Fusobacterium necrophorum . [ 30 142 143 144 ] Recently, researchers proposed that this infection could be spread through the fossa navicularis magna from the lymphatic tissue in the pharynx to the skull base, usually in patients with retropharyngeal abscess. [ 143 145 146 ] The lymphoid tissue of the pharyngeal tonsil and the presence of emissary veins in the fossa navicularis functioned as a potential route of infection spread and led to clival osteomyelitis.…”

A rare life‐threatening complication of acute mastoiditis: Case report and literature review

“… 5‐14 Patient age ranged from 17 to 94 years old with eight out of 10 cases occurring above the age of 50 years old. The initial chief complaint in each case varied, however, eight out of the 10 cases presented with neurologic symptoms, the most common being a headache 5‐7,9,11,13,14 . In all cases, CVST and SBO developed as secondary complications from a primary infectious etiology.…”

“…There have been only 10 other cases of CVST with SBO reported in literature to date (Table 1 ). 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 Patient age ranged from 17 to 94 years old with eight out of 10 cases occurring above the age of 50 years old. The initial chief complaint in each case varied, however, eight out of the 10 cases presented with neurologic symptoms, the most common being a headache.…”

Lemierre’s disease: a typical presentation in two diabetic patients

“…[20][21][22] In contrast, isolated XII cranial nerve involvement is found in two patients. 23,24 However clival osteomyelitis has also been associated with extensive thrombosis of the cavernous sinus, transverse sinus including internal carotid and vertebral artery. Extension of disease into cavernous sinus thrombosis has been reported to be accompanied by higher intracranial complications such as meningitis, brain abscess and subdural empyema, possibly as a result of spread from the same primary focus of infection.…”