title: Lemierre syndrome variant: Staphylococcus aureus associated with thrombosis of both the right internal jugular vein and the splenic vein after the exploration of a river cave.
abstract: BACKGROUND
  Lemierre syndrome is a rare and potentially fatal entity characterized by septic emboli from thrombosis of the internal jugular vein after oropharyngeal infection. The etiologic agent is not always an anaerobic bacterium. We report a patient with a Lemierre syndrome variant who presented with thrombosis of both the right internal jugular vein and the splenic vein as well as septic pulmonary emboli caused by Staphylococcus aureus, which proved resistant to methicillin, amoxicillin, and ciprofloxacin. The patient was thought to have acquired the infection during the exploration of a river cave in Turkey 10 days before his admission to the hospital. Such caves are natural reservoirs of infectious microorganisms.
  
  
  METHODS
  The patient had a physical examination, coagulation screening tests, tests of thrombin generation and fibrinolysis, coagulation inhibitors, activated protein C resistance, early and late serological tests (including autoantibodies), computed tomographic studies of the chest and abdomen, and bacterial examination of peripheral blood. Bacterial investigations were made on samples collected from the river cave.
  
  
  RESULTS
  After having undergone a 6 week course of antimicrobial treatment and anticoagulant therapy, the patient recovered from the infection with no residual complications, and the signs and symptoms of Lemierre syndrome resolved.
  
  
  CONCLUSIONS
  The results probably indicate an exposure of the patient to soil-based Staphylococcus aureus. This observation suggests the action of environmental factors that may contribute to the development of this rare syndrome.
authors.affiliation: Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Baskent University, 06490 Ankara, Turkey. drcanboga@hotmail.com
authors.forename: Can
authors.initials: C
authors.lastname: Boga
authors.forename: Hakan
authors.initials: H
authors.lastname: Ozdogu
authors.forename: Banu
authors.initials: B
authors.lastname: Diri
authors.forename: Levent
authors.initials: L
authors.lastname: Oguzkurt
authors.forename: Suheyl
authors.initials: S
authors.lastname: Asma
authors.forename: Mahmut
authors.initials: M
authors.lastname: Yeral
mesh_terms: D000328:Adult; D004617:Embolism / Q000382:microbiology; D006801:Humans; D007601:Jugular Veins / Q000000981:diagnostic imaging / Q000382:microbiology / Q000473:pathology*; D008297:Male; D010612:Pharyngitis / Q000382:microbiology*; D045483:Rivers / Q000382:microbiology; D012988:Soil Microbiology; D013162:Splenic Vein / Q000000981:diagnostic imaging / Q000382:microbiology / Q000473:pathology*; D013203:Staphylococcal Infections / Q000150:complications*; D013211:Staphylococcus aureus / Q000472:pathogenicity; D013577:Syndrome; D013927:Thrombosis / Q000382:microbiology*; D014069:Tonsillitis / Q000382:microbiology*; D014463:Ultrasonography