Abdominal Lemierre Syndrome – An Odd Presentation of a Rare Entity

Case description 39-year old hispanic male with no significant past medical history presented to the emergency department with complaints of sudden onset, progressively worsening, severe epigastric and right upper quadrant (RUQ) abdominal pain since 10 days. He also reported subjective fevers, chills, night sweats and unquantified weight loss for 2 weeks. On examination, he had a low-grade fever of 100.4 F, sinus tachycardia (100–110 bpm) and marked epigastric and RUQ tenderness without rebound tenderness, guarding or rigidity. Laboratory studies were remarkable for white blood cell count (WBC) of 16 × 109/ L with 84% neutrophils, total bilirubin of 2.2 mg/dl, with direct bilirubin of 1.0 mg/dl, mild transaminitis with ALT/AST of 135/98, alkaline phosphatase elevation at 355 and erythrocyte sedimentation rate of 107 mm/h. CT abdomen with contrast revealed right portal vein thrombosis (Figure 1). Hepatitis viral serologies, ANA, ASMA, LKM1 antibodies were all negative. He was empirically started on Ceftriaxone and metronidazole for possible pylephlebitis and therapeutic dose of enoxaparin was initiated. Initial blood and urine cultures showed no growth. He showed marked symptomatic improvement in his abdominal pain, remained afebrile, WBC and liver function tests normalized and he was discharged on day 5 with oral apixaban and hematology follow up. On the day following discharge, blood cultures from admission grew Fusobacterium nucleatum. Patient was informed of the results and prescribed another 10 days of metronidazole to complete a 2-week course. During a follow-up hematology visit 1 month later, patient was completely asymptomatic. Thrombophilia workup