- Email: [email protected]
Lemierre's variant
Review 84 Horvath J, Raffanti SP. Clinical aspects of the interactions between human immunodeficiency virus and the hepatotropic viruses. Clin Infect Dis 1994; 18: 339–47. 85 Gilson RJ, Hawkins AE, Beecham MR, et al. Interactions between HIV and hepatitis B virus in homosexual men: effects on the natural history of infection. AIDS 1997; 11: 597–606. 86 Scolfaro C, Fiammengo P, Balbo L, Madon E, Tovo PA. Hepatitis B vaccination in HIV-1-infected children: double efficacy doubling the paediatric dose. AIDS 1996; 10: 1169–70. 87 Zuin G, Principi N, Tornaghi R, et al. Impaired response to hepatitis B vaccine in HIV infected children. Vaccine 1992; 10: 857–60. 88 Banatvala J, Van Damme P, Oehen S. Lifelong protection against hepatitis B: the role of vaccine immunogenicity in immune memory. Vaccine 2000; 19: 877–85. 89 Black SB, Shinefield HR, Fireman B, Hiatt R. Safety, immunogenicity, and efficacy in infancy of
Vaccinating HIV-infected children
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91
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oligosaccharide conjugate Haemophilus influenzae type b vaccine in a United States population: possible implications for optimal use. J Infect Dis 1992; 165 (suppl 1): S139–43. Mulholland K, Hilton S, Adegbola R, et al. Randomised trial of Haemophilus influenzae type-b tetanus protein conjugate vaccine for prevention of pneumonia and meningitis in Gambian infants. Lancet 1997; 349: 1191–97. Gibb D, Giacomelli A, Masters J, et al. Persistence of antibody responses to Haemophilus influenzae type b polysaccharide conjugate vaccine in children with vertically acquired human immunodeficiency virus infection. Pediatr Infect Dis J 1996; 15: 1097–101. Read JS, Frasch CE, Rich K, et al. The immunogenicity of Haemophilus influenzae type b conjugate vaccines in children born to human immunodeficiency virus-infected women: Women and Infants Transmission Study Group. Pediatr Infect Dis J 1998; 17: 391–97. Madhi SA, Petersen K, Khoosal M, et al. Reduced
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effectiveness of Haemophilus influenzae type b conjugate vaccine in children with a high prevalence of human immunodeficiency virus type 1 infection. Pediatr Infect Dis J 2002; 21: 315–21. Nachman S, Kim S, King J, et al. Safety and immunogenicity of a heptavalent pneumococcal conjugate vaccine in infants with human immunodeficiency virus type 1 infection. Pediatrics 2003; 112: 66–73. Klugman KP, Madhi SA, Huebner RE, Kohberger R, Mbelle N, Pierce N. A trial of a 9-valent pneumococcal conjugate vaccine in children with and those without HIV infection. N Engl J Med 2003; 349: 1341–48. Schutze GE, Tucker NC, Mason EO, Jr. Failure of the conjugate pneumococcal vaccine to prevent recurrent bacteremia in a child with human immunodeficiency virus disease. Pediatr Infect Dis J 2001; 20: 1009–10. Paul Y. Herd immunity and herd protection. Vaccine 2004; 22: 301–2.
Clinical picture Lemierre’s variant Justin E Bekelman, John S Francis, Adam R Berliner, Cynthia J DeRuiter, and Cynthia D Brown
A 40-year-old woman with a history of endocarditis and intravenous heroine use presented with 3 days of fevers, rigors, and drenching sweats. Examination revealed poor dentition, normal heart sounds, bilateral groin sinus tracts, and tenderness in her left groin. Valvular vegetations were absent on transoesophageal echocardiography. The patient tested HIV-negative. Pelvic computed tomography showed bilateral sinus tracts extending from the skin surface, and a 2 cm soft tissue density and air bubble at the left femoral vein (figure). Ultrasound confirmed an occlusive thrombus of the left femoral vein. Blood cultures drawn before initiating empirical antibiotics subsequently grew oral flora, including Fusobacterium spp, Streptococcus viridans, Bacteriodes ureolyticum, Actinomyces spp, and Prevotella spp. Bilateral jugular venous ultrasound was negative for thrombus. On further history, the patient admitted to licking her heroin needles before groin insertion. The patient elected to be discharged from the hospital against medical advice. She received enoxaparin, warfarin, and a 6-week course of oral metronidazole and amoxicillin/clavulanate. The patient was last evaluated 6 weeks after her original presentation, at which time she was afebrile with evidence of resolving thrombus on Doppler ultrasonography. Her blood cultures were negative at that time. She was clinically improved, but continue to have left leg pain and symptoms of post-phlebitic syndrome. Our patient showed an alternative presentation of what some have called a forgotten disease. Fusobacterium bacteraemia associated with septic internal jugular vein thrombophlebitis was first described in The Lancet in 1936 by Lemierre in the context of oropharyngeal infection. Fusobacterium spp is a normal inhabitant of the oral cavity. Its unusual virulence stems from a lipopolysaccharide not shared by most other anaerobes of the mouth. We postulate
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that our patient developed a variant of Lemierre’s syndrome after insertion of an intravenous needle contaminated with oral flora. Treatment of deep venous septic thrombophlebitis consists of anticoagulation and a prolonged course of intravenous antibiotics. Venous ligation or surgical resection may be indicated for persistent septicaemia, progression of thrombosis, or septic embolism despite conservative efforts. JEB, CJD, ARB, and CDB are at the Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA. JSF is at the Division of Infectious Disease, Johns Hopkins Hospital, Baltimore. Correspondence: Dr Cynthia D Brown, Department of Medicine, Johns Hopkins School of Medicine, Suite 9020, 1830 East Monument Street, Baltimore, MD 21287, USA. Tel +1 410 955 7963; fax+1 410 955 0374; email [email protected]
Infectious Diseases Vol 4 August 2004
http://infection.thelancet.com
Vaccinating HIV-infected children
90
91
92
93
oligosaccharide conjugate Haemophilus influenzae type b vaccine in a United States population: possible implications for optimal use. J Infect Dis 1992; 165 (suppl 1): S139–43. Mulholland K, Hilton S, Adegbola R, et al. Randomised trial of Haemophilus influenzae type-b tetanus protein conjugate vaccine for prevention of pneumonia and meningitis in Gambian infants. Lancet 1997; 349: 1191–97. Gibb D, Giacomelli A, Masters J, et al. Persistence of antibody responses to Haemophilus influenzae type b polysaccharide conjugate vaccine in children with vertically acquired human immunodeficiency virus infection. Pediatr Infect Dis J 1996; 15: 1097–101. Read JS, Frasch CE, Rich K, et al. The immunogenicity of Haemophilus influenzae type b conjugate vaccines in children born to human immunodeficiency virus-infected women: Women and Infants Transmission Study Group. Pediatr Infect Dis J 1998; 17: 391–97. Madhi SA, Petersen K, Khoosal M, et al. Reduced
94
95
96
97
effectiveness of Haemophilus influenzae type b conjugate vaccine in children with a high prevalence of human immunodeficiency virus type 1 infection. Pediatr Infect Dis J 2002; 21: 315–21. Nachman S, Kim S, King J, et al. Safety and immunogenicity of a heptavalent pneumococcal conjugate vaccine in infants with human immunodeficiency virus type 1 infection. Pediatrics 2003; 112: 66–73. Klugman KP, Madhi SA, Huebner RE, Kohberger R, Mbelle N, Pierce N. A trial of a 9-valent pneumococcal conjugate vaccine in children with and those without HIV infection. N Engl J Med 2003; 349: 1341–48. Schutze GE, Tucker NC, Mason EO, Jr. Failure of the conjugate pneumococcal vaccine to prevent recurrent bacteremia in a child with human immunodeficiency virus disease. Pediatr Infect Dis J 2001; 20: 1009–10. Paul Y. Herd immunity and herd protection. Vaccine 2004; 22: 301–2.
Clinical picture Lemierre’s variant Justin E Bekelman, John S Francis, Adam R Berliner, Cynthia J DeRuiter, and Cynthia D Brown
A 40-year-old woman with a history of endocarditis and intravenous heroine use presented with 3 days of fevers, rigors, and drenching sweats. Examination revealed poor dentition, normal heart sounds, bilateral groin sinus tracts, and tenderness in her left groin. Valvular vegetations were absent on transoesophageal echocardiography. The patient tested HIV-negative. Pelvic computed tomography showed bilateral sinus tracts extending from the skin surface, and a 2 cm soft tissue density and air bubble at the left femoral vein (figure). Ultrasound confirmed an occlusive thrombus of the left femoral vein. Blood cultures drawn before initiating empirical antibiotics subsequently grew oral flora, including Fusobacterium spp, Streptococcus viridans, Bacteriodes ureolyticum, Actinomyces spp, and Prevotella spp. Bilateral jugular venous ultrasound was negative for thrombus. On further history, the patient admitted to licking her heroin needles before groin insertion. The patient elected to be discharged from the hospital against medical advice. She received enoxaparin, warfarin, and a 6-week course of oral metronidazole and amoxicillin/clavulanate. The patient was last evaluated 6 weeks after her original presentation, at which time she was afebrile with evidence of resolving thrombus on Doppler ultrasonography. Her blood cultures were negative at that time. She was clinically improved, but continue to have left leg pain and symptoms of post-phlebitic syndrome. Our patient showed an alternative presentation of what some have called a forgotten disease. Fusobacterium bacteraemia associated with septic internal jugular vein thrombophlebitis was first described in The Lancet in 1936 by Lemierre in the context of oropharyngeal infection. Fusobacterium spp is a normal inhabitant of the oral cavity. Its unusual virulence stems from a lipopolysaccharide not shared by most other anaerobes of the mouth. We postulate
518
that our patient developed a variant of Lemierre’s syndrome after insertion of an intravenous needle contaminated with oral flora. Treatment of deep venous septic thrombophlebitis consists of anticoagulation and a prolonged course of intravenous antibiotics. Venous ligation or surgical resection may be indicated for persistent septicaemia, progression of thrombosis, or septic embolism despite conservative efforts. JEB, CJD, ARB, and CDB are at the Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA. JSF is at the Division of Infectious Disease, Johns Hopkins Hospital, Baltimore. Correspondence: Dr Cynthia D Brown, Department of Medicine, Johns Hopkins School of Medicine, Suite 9020, 1830 East Monument Street, Baltimore, MD 21287, USA. Tel +1 410 955 7963; fax+1 410 955 0374; email [email protected]
Infectious Diseases Vol 4 August 2004
http://infection.thelancet.com