]ournal of Infection (1995) 31, 151-152

CASE REPORT

A Case of Fusobacterium necrophorum Sepsis

Michael J. Martin and Elizabeth D. Wright

Department of Microbiology, Worthin~ Hospital, West Sussex BN11 2DH, U.K.

Accepted for publication 30 November 1994

We present a case of Fusobacterium necrophorum sepsis following serologically confirmed infectious mononucleosis in a young adult male.

Introduction

We describe a case of Fusobacterium necrophorum infection in a 17-year-old male presenting an abscess formation in the deep layers of the anterior abdominal wall. Wide- spread pulmonary involvement is well recognised and superficial skin lesions have been described, but deep infection at a site distant from the throat without apparent metastatic spread elsewhere is an unusual presentation.

Case Report

A 17-year-old male presented to the accident and emer- gency department with a 4 day history of lower ab- dominal pain, fever, nausea and vomiting. He did not complain of a sore throat. About 4 weeks previously he had been diagnosed as having infectious mononucleosis. The Epstein Barr Virus Capsid Antibody titre was 64 and Nuclear Antibody titre O, and he still had enlarged lymph nodes in his axillae, groins and neck. His temperature was 41.1°C and he was very tender in the left groin and suprapubic area. Urine mircoscopy was negative. Full blood count revealed a haemoglobin of 13.2 g/dl, WBC count 4.3 x 109/1 and platelets 63 x 109/1. Blood cultures were taken and he was started on i.v. fluids, 1 g cefotaxime and 80 mg gentamicin 8-hourly.

On day 2 of admission his temperature had fallen to 37.5°C, his WBC count had risen to 14.5 x 109/1 and platelets to 116 ×109/1. The C-reactive protein was 159 mg/1. His temperature settled and antibiotics were stopped. By day 4: his temperature had risen to 38.4°C and he complained of severe pain in his left hip and was unable to walk. On examination he had reduced flexion of the left hip. The possibility of psoas abscess was considered but an abdominal CT-scan showed abscess formation in the deep layers of the anterior abdominal wall above and to the left of the pubic symphysis. There

was no evidence of involvement of the hip joint on CT- scan or X-ray. Aspiration under ultrasound guidance produced a purulent specimen. He was treated with 1 g flucloxacillin 6-hourly, 1.2 g benzylpenicillin 4-hourly, 2 g 8-hourly cefotaxime 8-hourly and 500 mg metro- nidazole 8-hourly, all given intravenously. He made little improvement on this regimen and after 48 h cefotaxime was stopped and 750 mg ciprofloxacin orally, 12-hourly was added. Defervescence occurred but he developed an itchy maculopapular rash characteristic of beta-lactam allergy. The flucloxacillin and benzylpenicillin were dis- continued, 500 mg erythromycin orally, 6-hourly was substituted and the metronidazole was also given orally. An anaerobic organism was isolated from the pus after 5 days of enrichment culture and identified as g necro- phorum, confirmed by the Anaerobe Reference Laborat- ory. The patient was discharged home to complete a total of 30 days antibiotic therapy and made a full recovery. A further CT-scan 6 weeks after presentation revealed resolution of the abscess with mild tissue thickening.

Discussion

E necrophorum has over 50 synonyms 1 and the classical syndrome in man is known as Lemierre's syndrome, ne- crobacillosis or post-anginal sepsis. 2'3 F. necrophorum is usually found as the sole pathogen, this is unusual in an- aerobic infections where several species are often present. The organism is characteristically fusiform (although fil- amentous forms may be seen), is nutritionally demanding and a strict anaerobe. 4 It is slow growing and micro- biological confirmation usually takes a few days. Hence the need for a clinical diagnosis which can be difficult with atypical presentations. The classical presentation is of severe sore throat, painful cervical lymphadenopathy and then a septicaemic illness involving multiple meta-

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152 A Case of Fusobacterium necrophorum Sepsis

static abscesses, usually in the lungs. 3 There is often em- pyema. 5 Pathogenesis is believed to be septic thrombo- phlebitis of the tonsillar veins spreading to involve the internal jugular veins thus producing a source for septic emboli. 2 The disease is found in previously fit young adults al though recent infectious mononuclesis has been im- plicated 6, z as a predisposing condition. Burden 2 disputes this, suggesting that a false positive monospot reaction occurs but Shel et al. 6 and Dagan and Powell 7 each report a case with specific antibody indicating recent Epstein Barr Virus infection. Our patient also had specific capsid anti- body. Meis et al. s describes a case following Mycoplasma

pneumoniae infection. A variety of atypical presentations have been described, m a n y involving the upper respiratory tract such as otitis media 1 and cervical abscess. 9 Cases of endocarditis, 1° meningitis 11 and hepatic abscess 12 have been described. Pancytopenia 13 and DIC 14 have been re- ported as complications but are rare. Our patient had a low platelet count at presentation which is well described) Superficial lesions of the skin have been reported, I5 but deep soft tissue infections distant from the upper re- spiratory tract are rare. Our case is unusual in that there was deep infection in the lower abdominal wall without apparent metastatic spread elsewhere and there was also no evidence of an inflamed throat al though we assume this was the organism's portal of entry during the pharyngitis of glandular fever. Because of the rarity of this condition there is little consensus on opt imum antimicrobial therapy but, prompted by the slow clinical response, it is suggested that it should be prolonged. 1 The organism is sensitive to pe- nicillin and metronidazole and while Eykyn suggests metronidazole as the definitive therapy she adds penicillin because streptococci have also been isolated from oc- casional patients. Our patient developed penicillin allergy and erythromycin was therefore substituted. As with other

anaerobes, aminoglycosides play no part in therapy. Sur- gical drainage where appropriate 9' 12 is an important part of t reatment as well as confirming the diagnosis.

References 1 Eykyn SJ. Necrobacillosis. Scand] Infect Dis 1989; 62 (Suppl):

47-51. 2 Burden P, Fusobacterium necrophorurn and Lemierre's syndrome. J

Infect 1991; 23: 227-231. 3 Lemierre A. On certain septicaemias due to anaerobic organisms.

Lancet 1936;i:701-703. 4: Moore-Gillon J, Lee TH, Eykyn S], Phillips f. Necrobacillosis: a

forgotten disease. BM] 1984; 288: 1526-1527. 5 Moreno S, Garcia-Altozano ], Pinilla Be t al. Lemierre's disease:

Post-anginal bacteraemia and pulmonary involvement caused by Fusobacterium necrophorum. Rev Infect Dis 1989; 11: 319-323.

6 8hek M, Karamali A, McGuire N, Seifert P, Alperia N, Dearborn M. Bacterial sepsis with Fusobacterium species. Arch Intern Med 1988; 148: 2303.

7 Dagan R, Powell KR. Post-anginal sepsis following infectious mono- nucleosis. Arch Intern Med 1987; 147: 1581-1583.

8 Meis JFGM, Polder TW, van der Kar P, Hoogkamp-Korstanje ]AA. Multiple brain abscesses and bacteraemia in a child due to Fu- sobacterium necrophorum. Infection 1993; 21: 174-176.

9 Chalstrey SE, Williams HOL, Reilly G. Necrobacillosis - an unusual cause of cervical abscess. J Laryngol Otol 1992; 106: 374-375.

10 Stuart G, Wren C. Endocarditis with acute mitral regurgitation caused by Fusobacterium necrophorum. Pediatr CardioI 1992; 13: 230-232.

11 Jacobs JA, Hendriks ]JE, Verschure PDMM et al. Meningitis due to Fusobacterium necrophorum subspecies necrophorum. Case report and review of the literature. Infection 1993; 21: 57-60.

12 Embree JE, Williams T, Law BJ. Hepatic abscess in a child caused by Fusobacterium necrophorum. Pediatr infect Dis J 1988; 7: 359-360.

13 Epstein M, Pearson ADJ, Hudson S], Bray R, Taylor M, Beesley ]. Necrobacillosis with pancytopenia. Arch Dis Child 1992; 67: 958-959.

14 Potter MN, Drysdale HC, Price PA, Buck AC. Disseminated intra- vascular coagulation with Fusobacterium necrophorum septicaemia. Postgrad Med ] 1988; 64: 155-156.

15 Ieven M, Vael K, De Mayer M, De Schepper A, Pattyn S. Three cases of Fusobacterium necrophorum septicaemia. Eur I Cltn Microbiol Infect Dis 1993; 12: 705-706.