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Year : 2023  |  Volume : 6  |  Issue : 1  |  Page : 40-41

Difficult airway management in a case of Lemierre's syndrome with diabetic ketoacidosis

1 Department of Anesthesia and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Department of Trauma and Emergency (Anesthesiology), All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission04-Aug-2022
Date of Acceptance20-Feb-2023
Date of Web Publication20-Apr-2023

Correspondence Address:
Dr. Ankur Sharma
Department of Trauma and Emergency (Anesthesiology), All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_34_22

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How to cite this article:
Lakshmikanth K, Sharma A, Paliwal B, Kuri H. Difficult airway management in a case of Lemierre's syndrome with diabetic ketoacidosis. Airway 2023;6:40-1

How to cite this URL:
Lakshmikanth K, Sharma A, Paliwal B, Kuri H. Difficult airway management in a case of Lemierre's syndrome with diabetic ketoacidosis. Airway [serial online] 2023 [cited 2023 Jun 7];6:40-1. Available from: https://www.arwy.org/text.asp?2023/6/1/40/374364

Lemierre's syndrome is an uncommon but potentially life-threatening illness characterised by septic thrombophlebitis of the head and neck veins as a consequence of oropharyngeal infection.[1] It is often caused by Fusobacterium necrophorum.[2]

A 25-year-old male who had diabetes mellitus for 2 years on insulin therapy presented to the emergency room with severe toothache and pus discharge for 10 days, fever for 5 days and altered sensorium, difficulty in swallowing and shortness of breath for 2 days. On examination, the patient had tender diffuse swelling with restricted mobility of the neck and mouth opening of 1.5 finger breadth [Figure 1]a.
Figure 1: (a) Restricted mouth opening in a patient with Lemierre's syndrome (b) Computed tomography showing right internal jugular vein thrombosis, (c) Point-of-care ultrasound showing internal jugular vein thrombosis

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Diabetic ketoacidosis was diagnosed initially in the emergency room because of blood sugar of 480 mg/dl, positive blood and urine ketones and metabolic acidosis on arterial blood gas analysis (ABG). Further evaluation with contrast-enhanced computed tomography of the paranasal sinus showed an oropharyngeal abscess involving left submandibular, pterygomandibular and submental spaces and left carotid space with the internal jugular vein thrombosis [Figure 1]b and [Figure 1]c. He was posted for emergency incision and drainage of the oropharyngeal abscess.

Patient ABG revealed a pH-7.12, PaO2 78 mm Hg, PaCO2 35 mm Hg, HCO3 14 meq/L, Na, 136 meq/l, K, 3.6 meq/L, and Cl of 103.6 meq/L. Correction with intravenous (IV) fluids and insulin was started in the emergency department and was continued in the preoperative room. An anatomical and physiologically difficult airway was anticipated in view of restricted mouth opening and neck movements, uncooperative patient and metabolic acidosis. Awake fibreoptic nasal intubation was regarded as the first choice and the primary management plan. An elective tracheostomy was the backup plan if awake intubation failed. Nebulisation with lignocaine 4% was commenced, and the left nostril was sprayed with 10% lidocaine. Conscious sedation was achieved with 1 mg IV midazolam and dexmedetomidine infusion at a loading dose of 1 μg/kg for 20 min, followed by 0.5 μg/kg/min. In the first attempt, fibreoptic bronchoscope was inserted through the left nostril while oxygen was given via the right nostril at 35 L/min. On the visualisation of vocal cords, 20 mg IV propofol was given because of the patient's movement while maintaining spontaneous ventilation. Subsequently, the patient's trachea was intubated. The intraoperative condition of the patient was stable, and he was maintained on an insulin infusion. Postoperatively, the patient was shifted to the intensive care unit with an endotracheal tube in situ. After revealing the cuff leak test negative, the patient was extubated after postoperative day 2. Following successful extubation, the patient was transferred to the ward to continue intravenous antibiotics and monitoring.

The anaesthesiologist faces many issues while treating neck soft-tissue infections.[3] Visualising the anatomy might be difficult due to airway oedema.[4] A collapsed airway and an inability to breathe are dangers of induction before the airway has been secured.[5] Although similar cases have been described in the literature, the patient in the present case was agitated and had diabetic ketoacidosis, which made management much more challenging.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.


We are thankful to our radiology colleagues for reporting the image and surgical colleagues to help in the management of this case.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Valerio L, Corsi G, Sebastian T, Barco S. Lemierre syndrome: Current evidence and rationale of the Bacteria-Associated Thrombosis, Thrombophlebitis and Lemierre syndrome (BATTLE) registry. Thromb Res 2020;196:494-9.  Back to cited text no. 1
Lee WS, Jean SS, Chen FL, Hsieh SM, Hsueh PR. Lemierre's syndrome: A forgotten and re-emerging infection. J Microbiol Immunol Infect 2020;53:513-7.  Back to cited text no. 2
Man MY, Shum HP, Yan WW, Lau SK. A case of Lemierre's syndrome in Intensive Care Unit. Indian J Crit Care Med 2018;22:122-4.  Back to cited text no. 3
[PUBMED]  [Full text]  
Karkos PD, Karkanevatos A, Panagea S, Dingle A, Davies JE. Lemierre's syndrome: How a sore throat can end in disaster. Eur J Emerg Med 2004;11:228-30.  Back to cited text no. 4
Cho JW, Jeong MA, Choi JH, Cho JW, Lee HJ, Kim DW, et al. Anesthetic consideration for patients with severe tracheal obstruction caused by thyroid cancer –A report of 2 cases. Korean J Anesthesiol 2010;58:396-400.  Back to cited text no. 5


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