A 28-year-old male-to-female transsexual presented with a sore throat and difficulty swallowing. Imaging showed an abscess on the left tonsil and thrombosis of the left internal jugular vein, consistent with Lemierre's syndrome. Lemierre's syndrome involves a neck infection leading to internal jugular vein thrombosis and potential sepsis. Estrogen levels in male-to-female transsexuals have been associated with higher risk of blood clots. This case illustrates the importance of monitoring transsexual patients on estrogen therapy for potential complications like Lemierre's syndrome.

1. RESEARCH POSTER PRESENTATION DESIGN © 2012
www.PosterPresentations.com
Lemierre's syndrome is a condition
characterized by thrombophlebitis of the
internal jugular vein and bacteremia following
a recent oropharyngeal infection (Image
below). Transsexualism is a rare condition with
few reports on long-term safety of different
treatment protocols and on the physical
outcomes of medical treatment.
There is no case report of internal jugular
thrombosis in those taking Estrogen hormone
therapy in the medical literature to the best of
our knowledge.
We are hereby presenting a case of a
transsexual on estrogen with suspected
Lemierre's syndrome.
A 28-year-old male to female transsexual and homosexual male on
ethanyl estradiol and Spiranolactone under the direction of a local
Transsexual clinic for one year, with a one time history of peritonsilar
abscess six years ago which was incised and drained without further
follow up, presented to the emergency department with a three day
history of sore throat, difficulty and painful swallowing. The patient
had taken a two day course of an unknown nonprescription antibiotic at
home, then felt acutely worse on the day of presentation. The patient
reported difficulty swallowing and pain upon opening the mouth and
denied fever, chills, cough, chest pain, shortness of breath, other upper
respiratory symptoms, or any other symptoms.
On physical exam patient was afebile, exhibited reduced ability to
open the oral cavity, severe pharyngeal erythema, bilateral tonsillar
enlargement and erythema partially occluding the airway, bilateral non-
tender jugulo-digastric node enlargement and Male Tanner Stage 5;
Female breast Tanner Stage 1. The patient had a leukocytosis of 13,800
with neutrophilia, Rapid streptococcal test: Negative, HIV/ Hepatitis
B: Negative. An estrogen level was ordered, resulting in 287.5 pg/mL.
CT scan with contrast of the neck: 8x5mm large left palatine tonsil
with phlegmenous/early abscess formation with associated upper
jugular lymphadenopathy, and lacked visualization of the proximal left
internal jugular vein, secondary to thrombosis.. A left internal jugular
vein thrombosis was confirmed by bedside ultrasound, demonstrating a
non-compressible hyper-echoic thrombus (Bedside image below).
A concern for Lemierre's disease and progression of disease to sepsis
led to blood cultures including anaerobic cultures, looking particularly
for Fusobacterium Necrophorum, and empirically treated with
piperacillin/tazobactam following local community resistance of
Fusobacterium to Clindamycin. Patient was started on therapeutic
anticoagulation with low molecular weight heparin. Inflammation and
erythema started declining. The patient was bridged to Coumadin.
Cultures remain negative. The patient was discharged on
Amoxicillin/clavulanic acid for five more days, Coumadin for 3
months with a recommendation not to continue on Estrogen during the
duration of Warfarin.
CASE PRESENTATION DISCUSSION
Internal Jugular Vein Thrombosis (IJVT) can be from a number
of known causes such as head and neck infections that travel
through post-pharyngeal spaces such as in this patient, or from
other causes such as malignancies, polycythemia,
hypercoagulable states, cervical injection drug use, surgery and
venous lines. Its known sequel include sepsis, papilladema, and
pulmonary embolism. This is an under diagnosed disease with
a complex and often subtle physical presentation. Lemierre’s
syndrome is life-threatening condition first described in 1936,
characterized by an acute pharyngeal infection with
Fusobacterium Necrophorum, and an associated IJV thrombosis
and sepsis with possible bacteremic emboli anywhere
downstream to infection such as pulmonary emboli that can
result in life threatening lung abscess and empyema.
Estrogen levels above the therapeutic level of 200 pg/mL have
been demonstrated to cause hyper-coagulable states in
prospective studies of male-to-female transsexuals. Hormone
replacement is associated with a higher risk of venous
thromboembolism, although the risk seemed to be restricted to
the first year of use. This case illustrates the importance of
closely monitoring those taking Estrogen hormone replacement
due to its diverse set of possible side effects.
Lemierre’s should be suspected in a patient in a hyper
thrombotic state with pharyngitis, persistent septic symptoms
despite treatment and possible pulmonary septic emboli.
REFERENCES
1. Sinave CP, Hardy GJ, Fardy PW. The Lemierre syndrome: suppurative
thrombophlebitis of the internal jugular vein secondary to oropharyngeal
infection. Medicine (Baltimore) 1989; 68:85.
2. Chirinos JA, Lichtstein DM, Garcia J, Tamariz LJ. The evolution of Lemierre
syndrome: report of 2 cases and review of the literature. Medicine (Baltimore)
2002; 81:458.
3. Asscheman H, Et al. Venous thrombo-embolism as a complication of cross-
sex hormone treatment of male-to-female transsexual subjects: a review.
Andrologia. 2013 Aug 15. doi: 10.1111/and.12150.
ACKNOWLEDGEMENT
John D'Angelo, DO
Chairman, Department of Emergency Medicine,
Trinitas Regional Medical Center
Paymon Ebrahimzadreh, MS III; Fateema Islam, MS III
Lemierre's syndrome in a Male-to-Female transsexual.
Vidya Kollu, MD
INTRODUCTION
Trinitas Regional Medical Center