Season 8 Case 35
History: neck and check pain. Swelling
Answer: Thrombophlebitis of the Left bracheocephalic vein with mediastinitis
Check out the new X-ray. We definitely see widening of the upper mediastinum. But can we be more specific? Where is the “mass”
We can see from our current exam that the contour of the aortic silhouette (red arrow) is maintained so it should not be adjacent to the aorta. If fact it actually obscures the left subclavianartery silhouette (yellow arrows) so it has to be in that region of the anterior mediastinum.
So what’s next? How about the CT?
Now we clearly see the extensive stranding throughout the anterior mediastinal fat, with severe narrowing of the left bracheocephalic vein and left jugular vein.
Finally we have the Doppler Ultrasound of the left jugular vein showing occlusion. In fact the left jugular and subclavian veins were thrombosed as centrally as able to be visualized.
What’s the source? Here’s a higher slice from the neck CT showing retropharengeal fluid likely relating to pharengeal infection.
In summary, we have thrombosis of the left jugular, subclavian and bracheocephalic veins with associated thrombophlebitis and mediastinitis preumably secondary to a pharyngeal infection. This is similar to a Lemierre’s Syndrome however classically that involved the internal jugular vein but here we have common jugular and distal thrombophlebitis.
Neck pain and swelling with ongoing/recent oropharengeal inection
generally 16-25 years old
80% caused by Gram (-) Fusobacterium necrophorum but can get polymicrobial even including MRSA
shows jugular vein thrombosis. US generally easiest and most straight forward but can be limited in the chest
CT/MR can be helpful for more central venous evaluation and to identify source/site of primary infection
Complications: Pulmonary Septic emboli and systemic dissemination
Treatment: Anticoagulation and IV Abx. Mortality rates can be as high at 18%.