Sir,

Necrobacillosis, the septicaemic disease caused by Fusobacterium necrophorum, is a rare and potentially fatal disease. The original description of Lemierre1 included fever, rigors, arthritis, and pulmonary infarct occurring after an episode of sore throat. The mortality and morbidity is commonly due to thrombotic complications and septicaemia. We report a case of F. necrophorum septicaemia causing orbital cellulitis and cavernous sinus thrombosis in a healthy young female patient.

Case report

A 23-year-old female patient was admitted to the infection unit with high fever (40°C) left facial swelling, right proptosis, diplopia, and decreased vision for 2 days. She had been treated with clarithromycin for a sore throat 3 weeks before presentation. Examination revealed visual acuity of 6/24 on the right and 6/5 on the left, proptosis (26 mm OD, 22 mm OS), conjunctival chemosis, and painful limitation of gaze.

CT scan revealed a left-sided parapharangeal abscess with a right-sided cavernous sinus thrombosis. Throat examination revealed a parapharyngeal abscess abutting the epiglottis. She underwent emergency left tonsillectomy with drainage of the abscess and was commenced on high-dose intravenous benzyl penicillin with metronidazole.

On the third day of admission, she developed left arm weakness and a right facial palsy. The MRI scan revealed diffuse swelling of right hemisphere with swollen right cavernous sinus and enhancement of adjacent sphenoid sinus (Figure 1). Blood and aspirate culture grew F. necrophorum sensitive to penicillin, metranidazole, and clindamycin. She received 4 weeks of the appropriate intravenous antibiotics and had a full recovery.

Figure 1
figure 1

Coronal MRI (T1, post-gadolinium) image showing enlarged right cavernous sinus and left parapharangeal abscess.

Full size image

Comment

F. necrophorum is a Gram-negative anaerobic commensal of human oropharynx. Its pathogenesis is attributed to endotoxin, lipopolysaccharide, and haemolysin. The lipopolysaccharide is shown to aggregate platelets and thought to be responsible for thrombotic complications of Lemierre's disease.2 F. necrophorum septicaemia tends to occur after a sore throat.3 Antibiotic therapy is the mainstay of treatment. Most species are susceptible to penicillin, cephalosporin, metronidazole, clindamycin, tetracycline, and chloramphenicol.4 In our case, the organism was sensitive to penicillin and metronidazole. Prolonged aggressive treatment and debridement are necessary.5 Culture of blood and aspirate from the abscess seems valuable in isolating the organism. F. necrophorum infection must be considered in any case of orbital cellulitis with other coexisting focus of infection or venous thrombosis.