Pediatric Lemierre syndrome of rhinosinusogenic origin complicated by bilateral cavernous sinus thrombosis: A case report.

BACKGROUND: Lemierre syndrome is a rare but potentially life-threatening septic thrombophlebitis classically following an oropharyngeal infection, most often associated with Fusobacterium necrophorum. Atypical head and neck sources and unusual patterns of venous thrombosis have increasingly been reported. CASE PRESENTATION: We report the case of a 13-year-old boy admitted with fever, meningeal syndrome, left cervical swelling, ptosis, anisocoria, and altered consciousness following a short history of dental pain and fever. Contrast-enhanced cerebral and cervicothoracic computed tomography established the diagnosis of Lemierre syndrome of rhinosinusogenic origin, revealing left maxillary sinusitis complicated by a left medial pterygoid muscle abscess, thrombophlebitis of the left internal jugular vein and its tributaries, bilateral cavernous sinus thrombosis, left superior ophthalmic vein thrombosis, diencephalic ischemic stroke, and bilateral pulmonary septic embolic lesions. Blood cultures obtained before antibiotic therapy remained negative, and no focal microbiological specimen was available because no surgical drainage was performed. The patient received intravenous ceftriaxone, metronidazole, and an aminoglycoside, followed by low-molecular-weight heparin because of extensive intracranial venous thrombosis. Corticosteroids were also administered for severe orbital involvement. The clinical course was favorable, with complete clinical and radiological recovery after six weeks of antibiotic therapy. CONCLUSION: This case illustrates that complicated pediatric rhinosinusitis may present as a multidirectional Lemierre-like septic thrombophlebitis involving cervicofacial, orbital, intracranial, and pulmonary territories, even when cultures are negative. It also highlights that favorable outcome may be achieved without surgical drainage when no accessible collection is identified, provided that broad antimicrobial therapy, selected anticoagulation, and close multidisciplinary monitoring are rapidly implemented.