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Lemierre’s syndrome masking metastatic lung adenocarcinoma
  1. Revati Naran1,
  2. Vruti Dattani2,
  3. Yasser Madani3
  1. 1Respiratory Medicine, Barking Havering and Redbridge Hospitals NHS Trust, Romford, UK
  2. 2Radiology, Royal Free London NHS Foundation Trust, London, UK
  3. 3Respiratory Medicine, Frimley Health NHS Foundation Trust, Frimley, UK
  1. Correspondence to Dr Revati Naran, Respiratory Medicine, Barking Havering and Redbridge Hospitals NHS Trust, Romford RM7 0AG, UK; revati.naran{at}nhs.net

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RN: specialty trainee in respiratory medicine

A 52-year-old woman presented to the emergency department (ED) with a 1-week history of right lower chest and upper quadrant pain and sore throat. She also reported a 2-day history of fever, rigours and productive cough. Her medical history was significant for chronic obstructive pulmonary disease with a significant smoking history of 51 pack-years. Regular medications included tiotropium, seretide/fluticasone and ventolin.

On initial examination, she was hypotensive (blood pressure 95/60 mm Hg), tachycardic (heart rate 104 bpm) and febrile (temperature 38.2°C). There were no stigmata of infective endocarditis on inspection of the peripheries. An erythematous, fluctuant, tender swelling measuring 2–3 cm in diameter was present in the left submandibular region. Chest auscultation revealed coarse crackles at the right lung base. Her abdomen was soft and non-tender.

Blood tests showed elevated white cell count (WCC) 26.5×109 /L and C-reactive protein (CRP) 295 mg/L and an acute kidney injury (creatinine 113 µmol/L). A chest X-ray (CXR) (figure 1) demonstrated a right-sided pleural effusion with multiple rounded opacities bilaterally. While in ED she was treated with intravenous fluids and initial doses of intravenous broad-spectrum antibiotics. The patient went on to have a CT scan of the chest, abdomen and pelvis (figure 2), given concerns about sepsis with an unclear source, abdominal pain, the cause of which was also uncertain and the abnormal CXR.

Figure 1

AP chest X-ray demonstrating bilateral rounded opacities and a right-sided pleural effusion). AP, anteroposterior.

Figure 2

Axial sections from postcontrast CT chest. Lung window images (A, B) show bilateral lung lesions, one of which demonstrates the reversed halo sign. Soft-tissue window images (C, D) show right-sided peripherally enhancing pleural collections containing gas locules.

VD: specialty trainee in clinical radiology

The CT scan showed bilateral lung lesions, many demonstrating a reversed halo sign (thick walled lesions with central ground glass opacification) or central cavitation as well as several right-sided peripherally enhancing pleural …

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Footnotes

  • Contributors All authors contributed equally to the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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