Lemierre's syndrome: current perspectives on diagnosis and management

Pediatric Patient with Lemierre Syndrome of the External Jugular Vein: Case Report and Literature Review

Introduction  Lemierre syndrome (LS) involving the external jugular vein (EJV) is rare, and only a few cases have been reported in the literature. Objectives  To report a case of LS involving the external jugular vein as well as to make a review of the literature regarding both diagnosis and management strategies. Data Synthesis  We describe a case of LS involving the EJV and review the literature of previously published articles to search for additional cases. A PubMed, Embase, Scopus, and Web of science-based search was performed to determine the scope of coverage in well-reported articles in English. Twenty-one papers were retrieved and documented for age, incidence, pathogen, presenting symptoms, imaging, treatment, and outcome, which were noted for each of these cases. In our literature review of 21 papers, there were 16 patients (61%) in their 2nd and 3rd decades of life. Lemierre syndrome was shown to affect females and males equally. The presenting symptoms were a sore throat and fever. Treatment requires intravenous antibiotics, and there is no consensus regarding treatment with anticoagulation. Conclusions  The present case report and review of the literature emphasize the importance of history taking as well as physical examination in what seems to be a case of simple tonsillitis.

Lemierre's syndrome caused by Klebsiella pneumoniae: A case report

BACKGROUND

Lemierre's syndrome is a disease that causes anaerobic sepsis, internal jugular vein thrombosis, and septic embolism in the lungs and other organs after acute oropharyngeal infection. It was named after André-Alfred Lemierre in 1936.

CASE SUMMARY

Here, we have reported a case of Lemierre’s syndrome in a 56-year-old female patient who presented with a sore throat. The patient had septic shock, had not voided, and had severe hyperglycemia at the time of her visit. Imaging tests revealed bilateral pneumonia, pleural effusion, pulmonary embolism, and renal vein thrombosis. The patient was admitted to the intensive care unit and placed on mechanical ventilation due to acute respiratory distress syndrome. Continuous renal replacement therapy was administered to treat renal failure with anuria. Klebsiella pneumoniae was cultured from blood and sputum samples. After reviewing various results, the patient was ultimately diagnosed with Lemierre’s syndrome. The patient was treated with appropriate antibiotics and thrombolytic agents. She was discharged from the hospital after recovery.

CONCLUSION

Lemierre’s syndrome is associated with a high mortality rate. Therefore, clinicians should be familiar with the signs and symptoms of this disease as well as the preemptive examinations, procedures, and treatments.

Lemierre Syndrome in a Patient With Splenectomy Secondary to Pyruvate Kinase Deficiency, Complicated by Heparin Resistance

Lemierre syndrome was first documented in the literature in 1936, and is defined as septic thrombophlebitis of the internal jugular vein. It is typically a result of oropharyngeal infection causing local soft tissue inflammation, which spreads to vasculature, and promotes formation of septic thrombi within the lumen, persistent bacteremia, and septic emboli. We present the case of a 24-year-old incarcerated man, who presented with leukocytosis and a right-sided tender, swollen neck after undergoing left mandibular molar extraction for an infected tooth. Computed tomography revealed a persistent thrombus in the transverse and sigmoid sinuses bilaterally, extending downwards, into the upper jugular veins. He was started on empiric intravenous vancomycin, zosyn, and heparin, but subsequently demonstrated heparin resistance, and was thus anticoagulated with a lovenox bridge to warfarin. Throughout his hospital course, hemocultures demonstrated no growth, so antibiotic treatment was deescalated to oral metronidazole and ceftriaxone. On discharge, the patient was transitioned to oral amoxicillin and metronidazole for an additional 4 weeks with continuation of anticoagulation with warfarin for a total of 3 to 6 months. This case report details a unique presentation of Lemierre syndrome with bilateral transverse sinus, sigmoid sinus, and internal jugular vein thrombosis that was presumably secondary to an odontogenic infectious focus.

Severe case of Lemierre syndrome with multiple neurological and ophthalmological sequelae

A 56-year-old man was admitted to intensive care with septic shock, multiple facial abscesses and thrombophlebitis of the right internal jugular vein with extensive intracranial extension. A diagnosis of Lemierre syndrome due to Streptococcus anginosus was made and treatment initiated with high-dose ceftriaxone and metronidazole, along with surgical debridement. His admission was complicated by raised intraocular pressures and visual loss requiring bilateral canthotomies. Despite therapeutic anticoagulation with enoxaparin, he also developed an ischaemic basal ganglia infarct. After a prolonged and complex hospital stay, the patient was later readmitted with an intracerebral abscess requiring surgical excision and a second course of antibiotics. This case highlights the value of early recognition of this rare but potentially life-threatening condition, considerations around anticoagulation and antibiotic decisions, and the importance of close multidisciplinary follow-up even after discharge from hospital.

Lemierre's syndrome in adulthood, a case report and systematic review

Introduction: Lemierre's syndrome is a septic thromboembolic complication of an oropharyngeal or neck infection, primarily caused by Fusobacterium species. Although it usually affects young healthy patients, some case reports describe this syndrome in older population.Methods: A case report and a systematic review of the literature were conducted to investigate the late onset of Lemierre's syndrome. Forty-one articles were selected for the qualitative analysis, 39 for the quantitative analysis.Results: The average age of the study population was 52 years old. Diabetes mellitus and upper gastro-intestinal malignancy, common comorbidities in the study population, might play a role in the development of late-onset Lemierre's syndrome. Empiric antibiotic treatment should cover Fusobacterium and Streptococcus species both, which may cooperate to induce purulent disease. Reported unfavourable outcome was more than expected.Conclusion: Lemierre's syndrome in adulthood may differ from the usual version. This disease may further pass unrecognized, if presented out of the expected age range. Nevertheless, early diagnosis and prompt treatment are a requisite to prevent morbidity and mortality, which may be higher in this older population.

Forgotten disease: an atypical case of Lemierre syndrome presenting as a soft tissue abscess

Lemierre syndrome (LS) is an acute oropharyngeal infection with secondary septic thrombophlebitis and distant septic embolisation. A 29-year-old woman with sore throat, dyspnoea and left shoulder pain, who was on levofloxacin for 3 days, presented with worsening symptoms. She was tachycardic, tachypneic and hypoxic on presentation. CT of neck and chest revealed multiple loculated abscesses on her left lower neck and shoulder, right peritonsillar abscess, thrombosis of the right external jugular vein and multiple bilateral septic emboli to the lungs. She was started on clindamycin and ampicillin sulbactam for LS. She developed septic shock and required intubation due to respiratory failure. Drainage of the left shoulder abscess grew Fusobacterium nucleatum After 2 weeks of a complicated intensive care unit stay, her haemodynamic status improved and she was transferred to the floor. LS has variable presentations, but regardless of the presentation, it is a potentially fatal disease-requiring prompt diagnosis and management.

Pharyngeal abscess complicated by Lemierre's syndrome: Identification of an atypical germ

INTRODUCTION

Lemierre's syndrome is a rare but serious complication of an oral infection mostly related to Fusobacterium necrophorum. This condition combines jugular vein thrombosis and septic emboli to the lungs or other organs.

CASE PRESENTATION

We report here an original case of a pharyngeal abscess complicated by Lemierre's syndrome in a young healthy male patient. Samples taken from the pus of the pharyngeal abscess showed the presence of Gardnerella vaginalis associated with Fusobacterium necrophorum. The patient was treated by draining the abscess, antibiotic therapy and preventive anticoagulation for 1 month. The evolution was good with a resolution of the thrombosis.

CONCLUSIONS

This case highlights the need for bacterial identification to adapt antibiotic therapy in Lemierre's syndrome. It also shows the possibility of extragenital localization of Gardnerella vaginalis in a male patient having oral sex with women. In contrast to sexually transmitted infections such as syphilis and pharyngeal gonococcus, this oral localization of Gardnerella vaginalis has not been described previously in the literature.

Postoperative Lemierre’s syndrome: a previously unreported complication of transoral surgery. Illustrative case

BACKGROUND

Lemierre’s syndrome is a rare but potentially life-threatening clinical condition characterized by bacteremia and thrombophlebitis of the internal jugular vein, usually secondary to oropharyngeal infection and often caused by Fusobacterium necrophorum; rarely, it occurs after surgical procedures. The most common clinical presentation includes acute pharyngitis, high fever, and neck pain. The diagnosis is based on blood culture and cranial and cervical spine computed tomography (CT)/magnetic resonance imaging (MRI) with contrast. Antibiotic therapy for 3–6 weeks is the mainstay of treatment, while the use of anticoagulant drugs is controversial.

OBSERVATIONS

The authors describe a case of Lemierre’s syndrome that occurred after transoral surgery. The patient underwent a combined surgical approach from above (transoral) and below (anterolateral transcervical) to the upper cervical spine for the resection of a large anterior osteophyte causing dysphagia, globus sensation, and dysphonia. Three weeks after the surgical procedure, she developed fever and severe neck pain.

LESSONS

The aim of this paper is to consider Lemierre’s syndrome as a possible complication after the transoral approach, underlining the importance of its early diagnosis and with a suggestion to perform cranial and cervical spine CT or MRI venous angiography in patients who undergo surgery with a transoral approach and exhibit local or systemic signs of infection such as neck pain, persistent fever, and positive blood culture results.

Anterior cervical osteophytes causing dysphagia: Choice of the approach and surgical problems

Background

Anterior cervical osteophytes (ACOs) may rarely cause dysphagia, dysphonia, and dyspnea. Symptomatic ACOs are most commonly located between C3 and C7, whereas those at higher cervical (C1-C2) levels are rarer. We report a case series of 4 patients and discuss the best surgical approach according to the ostheophyte location and size, mainly for those located at C1-C2, and the related surgical problems.

Materials and Methods

Four patients (two males and two females) aged from 57 to 72 years were operated on for ACOs, causing variable dysphagia (and dyspnea with respiratory arrest in one). Three patients with osteophytes between C3 and C5 were approached through antero-lateral cervical approach, and one with a large osteophyte between C1 and C3-C4 level underwent a two-stage transcervical and transoral approach. All had significant postoperative improvement of dysphagia.

Results

The patient operated on though the transoral approach experienced postoperative flogosis of the prevertebral tissues and occipital muscles and thrombosis of the right jugular vein and transverse-sigmoid sinuses (Lemierre syndrome).

Conclusion

The transoral approach is the best surgical route to resect C1 and C2 ACOs, whereas the endoscopic endonasal approach is not indicated. The anterior transcervical approach is easier to resect osteophytes at C3, as well as those located below C3. A combined transoral and anterior cervical approach may be necessary for multilevel osteophytes.

Lemierre Syndrome: Unusual Presentation With Superior Ophthalmic Vein Thrombosis

ABSTRACT

Lemierre syndrome (LS) is a rare, but serious condition most commonly associated with oropharyngeal bacterial infection. Infection results in thrombophlebitis of the internal jugular vein and its tributaries. It usually affects previously healthy young adults. The authors report an unusual case of an elderly patient with penicillin allergy who developed Lemierre syndrome from an odontogenic infection (Streptococcus intermedius) resistant to clindamycin. She developed thrombosis of the internal jugular vein and superior ophthalmic vein resulting in visual changes. Treatment required incision and drainage, intravenous antibiotics and anticoagulation. Antibiotics were tailored to culture and sensitivities after testing response to a beta-lactam. With antibiotic resistance increasing, investigation of penicillin allergies is warranted for severe head and neck infections.

A teenager with fever, chest pain, and respiratory distress during the coronavirus disease 2019 pandemic: a lesson on anchoring bias

Symptoms of coronavirus disease 2019 overlap with other important illnesses affecting young adults. We report a case of a 17-year old male presenting to the emergency department in the midst of a pandemic with symptoms of coronavirus disease 2019. He had fever, dyspnea, chest pain, and myalgias, with bilateral infiltrates on chest radiograph, and developed septic shock secondary to infectious thromboembolic events. However, his blood cultures grew group G streptococcus secondary to his oropharyngeal infection, and he experienced an infectious thrombus in the internal jugular vein, consistent with the rare but well-described Lemierre's syndrome. This case report calls attention to the importance of maintaining differential diagnoses and thereby minimizing the biases and assumptions that come with clinical care during a pandemic.

Throat Microbial Community Structure and Functional Changes in Postsurgery Laryngeal Carcinoma Patients

The microbial community structure in the throat and its shift after laryngectomy in laryngeal squamous cell carcinoma (LSCC) patients were investigated. Thirty swab samples taken prior to laryngectomy (SLC), 18 samples 1 week after laryngectomy (SLCA1w), and 30 samples 24 weeks after laryngectomy (SLCA24w) from 30 LSCC patients were examined. Microbial diversity was profiled through sequencing the V3-V4 variable region of the 16S rRNA gene. Quantitative real-time PCR (qPCR) was used to validate the 16S rRNA sequence data for the V3-V4 region. The community structure and function of throat microbiota were assessed by PICRUSt (phylogenetic investigation of communities by reconstruction of unobserved states) analysis. Both alpha and beta diversity results showed significant differences in the throat microbiota of LSCC patients before and after laryngectomy (P < 0.05). The drinking index of the SLC group was positively associated with the genus abundance of Prevotella (P < 0.05). The SLCA1w group had lower abundances of Fusobacterium, Leptotrichia, Lachnoanaerobaculum, and Veillonella than the SLC group (P < 0.05). The SLCA24w group had higher abundances of Streptococcus and Leptotrichia as well as lower abundances of Fusobacterium and Alloprevotella than the SLC group (P < 0.05). The throat microbiomes of the SLC group could be implicated in human cancer signaling pathways, as evidenced by PICRUSt analysis (P < 0.05). Our study clarifies alterations in throat microbial community structure and function in LSCC patients during the perioperative period and postoperative recovery period.IMPORTANCE Laryngeal squamous cell carcinoma greatly impacts patients' lives, and noninvasive means of prognostic assessment are valuable in determining the effectiveness of laryngectomy. We set out to study the microbial structure changes in the throat before and after laryngectomy and found the gene functions of several throat bacteria to be associated with human cancer signaling pathways. Our findings may offer insights into the disease management of patients with laryngeal squamous cell carcinoma. We hope to provide a means of using molecular mechanisms to improve the prognosis of laryngeal cancer treatment and to facilitate relevant research.

Lemierre's syndrome involving milleri group streptococci: further insight into age and aetiology

Lemierre's syndrome (LS) is a suppurative thrombophlebitis of the internal jugular vein secondary to otorhinolaryngologic infection. It is classically associated with the Gram-negative anaerobe Fusobacterium necrophorum (FN) and is thought to be a disease of young people. Here, we describe the case of a 56-year-old woman with LS involving milleri group streptococci (MGS), which has been reported only 13 times since it was first observed in 2003. Subgroup analysis of all published cases of LS involving MGS demonstrated these patients were significantly older than those involving FN (median age 49 years versus 18 years, p = 0.007, IQR 36-58 years), although this finding is limited by publication bias. This report clarifies a 2014 hypothesis regarding the relationship between age and aetiology in this rare disease. While FN remains the most common cause of LS overall, empiric antibiotic therapy should also cover oral streptococci such as MGS, even in younger adults.

Anticoagulation Strategies in the Management of Lemierre Syndrome: A Systematic Review of the Literature

OBJECTIVE

To determine the optimal anticoagulation strategy in patients diagnosed with Lemierre Syndrome (LS).

DATA SOURCES

A systematic review in accordance with PRISMA guidelines was conducted using PubMed, MEDLINE, Scopus, ProQuest, and CINAHL from January to April 2020. Search terms included "Lemierre Syndrome" AND "anticoagulation" NOT "prophylaxis" OR "atrial fibrillation," in addition to a list of parenteral and oral anticoagulants. Adult patients who developed a clot and required systemic anticoagulation as a result of LS were included in this review.

STUDY SELECTION AND DATA EXTRACTION

A total of 4180 records were initially identified, though following the removal of duplicates and nonrelevant entries, 216 full-text articles were reviewed for inclusion; 13 articles were ultimately included.

DATA SYNTHESIS

The majority (11/14) of patients developed thromboses of the internal jugular veins, which corresponds to the pathophysiology of LS. Anticoagulation strategies were varied in the included literature, though 12/14 patients initially received a parenteral product. Two patients received a direct-acting oral anticoagulant (DOAC) following either intravenous heparin or subcutaneous enoxaparin and had outcomes similar to patients transitioned to warfarin.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Anticoagulation in LS is a clinical controversy because the thromboembolic events have rarely led to significant complications; thrombi typically resolve independently, and concerns for bleeding risks are well founded; however, this review indicates both the efficacy and safety of anticoagulation.

CONCLUSIONS

Anticoagulation is both efficacious and safe in LS, including treatment using a DOAC. Although further studies are needed, clinicians should consider a duration of anticoagulation of 6 to 12 weeks.

A Challenging Case of Lemierre’s Syndrome With Central Nervous System Involvement and a Comprehensive Review

Lemierre’s syndrome (LS) is a complex medical condition that is characterized by an acute oropharyngeal infection leading to thrombophlebitis of the internal jugular vein and an eventual metastatic spread to distant vital organs. This metastatic spread is from septic emboli and is most frequently seen in the lungs, kidneys, and large joints. Central nervous system (CNS) involvement in LS is extremely rare, and only a few cases of CNS involvement have been reported in the literature. For all cases of LS, early diagnosis and treatment are crucial, yet due to the rarity of CNS complications in LS, diagnostic patterns and treatment algorithms are not fully understood for this subset of presentations. In this report, we present a case of 19-year-old immune-competent female who presented with a Fusobacterium oropharyngeal infection that was complicated by suppurative sinusitis, cavernous sinus thrombosis, meningitis, and an abducens nerve palsy. Our patient was treated with broad-spectrum antibiotics, anticoagulation, and multiple surgical interventions. This case highlights the importance of an early diagnosis and a multidisciplinary approach in managing LS to minimize the mortality and long-term morbidity of this relatively rare and complicated multisystem disease.

A Rare Case Report of Lemierre Syndrome from the Anterior Jugular Vein

Introduction

Lemierre syndrome is a rare, potentially fatal, septic thrombophlebitis of the internal jugular vein. Treatment includes intravenous antibiotics for Fusobacterium necrophorum, the most common pathogen, as well as consideration for anticoagulation therapy.

Case Report

A 27-year-old female presented with left-sided neck swelling and erythema. Computed tomography noted left anterior jugular vein thrombophlebitis and multiple cavitating foci, consistent with septic emboli. We report a rare case of Lemierre syndrome in which the thrombus was found in the anterior jugular vein, as opposed to the much larger internal jugular vein more traditionally associated with creating septic emboli.

Conclusion

Based on an individual’s clinical symptoms, history, and radiologic findings, it is important for physicians to consider Lemierre syndrome in the differential diagnosis, as the condition may rapidly progress to septic shock and death if not treated promptly. The use of anticoagulation therapy remains controversial, and there is a lack of established standard care because the syndrome is so rare.

A Systematic Review of Lemierre's Syndrome With a Focus on Ophthalmologic Complications

Lemierre's syndrome (LS), once known as "the forgotten disease," is a rare and potentially life-threatening condition that has had a gain in incidence over the last 30 years due to a variety of factors that could include changes in antibody prescription patterns, particularly in regard to the treatment of pharyngitis/tonsillitis. Due to its low incidence and broad spectrum of symptoms, LS does not have an obvious clinical diagnosis and can confuse the clinician managing the patient. Furthermore, it is equally difficult to treat patients suffering from LS as it requires a multidisciplinary approach from multiple subspecialties. Thus, communication between hospitalists, radiologists, otolaryngologists, neurologists, and ophthalmologists is critical towards quickly diagnosing the disease condition so that prompt antibiotics, anticoagulation, and surgical intervention can occur. Atypical presentations can also exist, making the diagnosis and management exponentially more challenging. Ophthalmologic symptoms are a particularly rare and atypical presentation of LS. These rare symptoms in LS can be terrifying for patients and providers alike; yet, there does not seem to be any modern medical literature that summarizes ophthalmologic complications for LS patients. To our knowledge, this is the first systematic review of LS with a focus on ophthalmologic complications that has been done. The main objective of this review paper is to provide an up-to-date literature review of LS epidemiology, pathophysiology, diagnosis, and treatment while also performing a novel systematic review of reported cases of LS with ophthalmological complications. We hope to bring more awareness towards LS and its atypical presentations so that physicians will be better able to rapidly diagnose and treat their patients in order to minimize long-term morbidity and mortality.

Lemierre's syndrome treated operatively

Lemierre's syndrome (LS) is a pharyngeal infection complicated by infectious jugular vein thrombosis and septic emboli. Most commonly caused by Fusobacterium necrophorum, it may result in metastatic infection, especially when antibiotic treatment is delayed. Patients with LS are often healthy adults between 16 and 30 years who present with prolonged symptoms of pharyngitis, lateral neck pain, and fever. Other symptoms may include shortness of breath, tachycardia, and hypotension. When administered promptly, antibiotics can act as an effective treatment. However, complications may arise that require additional intervention. Herein, we report a case of LS in a young adult, complicated by severe pleural effusions that required surgical decortication.

[Cervicofacial cellulitis complicated by internal jugular vein thrombosis]

INTRODUCTION

Cervicofacial cellulitis (CFC) is one of the most common dermatological infectious emergencies, and related morbidity and mortality are non-negligible.

PATIENTS AND METHODS

We describe the case of a 31-year-old male with left parotitis complicated by CFC with worsening over the previous week despite treatment with clindamycin and non-steroidal anti-inflammatory drugs. A cervicofacial computed tomography (CT) scan showed left internal jugular vein thrombosis (IJVT). Chest imaging showed no pleuropulmonary lesion, and bacteriological samples were negative. The patient received broad-spectrum antibiotic therapy and anticoagulants for 6 weeks. The outcome was quickly favourable.

DISCUSSION

It is essential to perform a cervicofacial contrast-enhanced CT scan for any CFC to map the affected areas, detect the primary infection and screen for loco-regional complications such as IVJT. The occurrence of IJVT in an infectious setting should prompt screening for septic emboli, especially pulmonary emboli, as well as performance of a chest CT scan. The presence of septic emboli associated with a recent ENT infection and of IJVT or Fusobacteriumnecrophorum in blood cultures are indicative of Lemierre's syndrome.

CONCLUSION

IJVT is an uncommon complication of CFC that occurs either alone or as part of Lemierre's syndrome.

A Rare Case of Lemierre's Syndrome Caused by Streptococcus Intermedius, Presenting as an Epidural Abscess

Lemierre's syndrome is a rare but life-threatening condition characterized by an oropharyngeal infection typically secondary to Fusobacterium necrophorum resulting in septic thrombophlebitis of the internal jugular vein. Streptococcus intermedius is a particularly rare cause of Lemierre's syndrome with only a few cases reported in the literature. Here we describe a rare case of Lemierre's syndrome, caused by Streptococcus intermedius, likely secondary to an odontogenic infection, found to have a cervical epidural abscess with concomitant large retropharyngeal and prevertebral abscesses on presentation, in whom the clinical course was further complicated by an extensive cerebral venous sinus thrombosis. However, despite grave complications, early diagnosis and appropriate emergency management including intravenous antibiotics and surgical intervention led to a successful recovery, thus demonstrating that aggressive measures can potentially lead to a favorable outcome. 

Deep neck space infection and Lemierre's syndrome caused by Streptococcus anginosus: A case report

Introduction

Deep neck space infections most commonly arise from a septic focus of the mandibular teeth, tonsils, parotid gland, middle ear or sinuses, usually with a rapid onset and frequently with progression to life-threatening complications. Lemierre’s syndrome is classically defined by an oropharyngeal infection with internal jugular vein thrombosis followed by metastatic infections in other organs.

Case presentation

A 32-year-old female patient, with no significant past medical history, was diagnosed with a dental abscess on her left inferior 3^rd molar. Six days later, the condition complicated with severe upper respiratory distress, odynophagia and trismus, and extension of the inflammatory signs to the anterior cervical region, involving the upper airway. Computed tomography scan confirmed extension to submandibular, parapharyngeal and retrosternal spaces), which required nasotracheal intubation due to compromised airway. Urgent and subsequent surgical drainages were performed, alongside with concomitant antibiotic therapy. Additionally, left internal jugular vein thrombosis was described - with later extension to the brachiocephalic vein, without other complications, consistent with Lemierre's syndrome, although without full features. Streptococcus anginosus was identified in the drained pus specimens. The patient made a satisfactory clinical progress and was discharged after 25 days, still under therapeutic hypocoagulation.

Conclusion

As deep neck space infections can be life-threatening, clinicians must be aware and not underestimate their potential severity. Lemierre's syndrome is a complication difficult to recognize, which requires additional awareness of the many possible presentations, for appropriate diagnostic studies and therapeutic plan.

Lemierre's syndrome caused by Streptococcus pyogenes in an elderly woman

Lemierre's syndrome is characterized by septic thrombophlebitis of the internal jugular vein. It typically presents in healthy adolescents or young adults, usually preceded by an oropharyngeal infection, with the most common offending pathogen being Fusobacterium necrophorum. We present a case of Lemierre's syndrome in an elderly woman without antecedent oropharyngeal infection, caused by Streptococcus pyogenes. She was successfully treated with combined surgical and medical management.

Case of internal jugular vein thrombosis and fever: Lemierre's syndrome or Trousseau's syndrome?

Internal jugular vein thrombosis is a rare critical cardiovascular emergency, which has potential catastrophic clinical outcomes by resulting in stroke and pulmonary embolism. Several etiologies have been reported; however, there are limited data on Lemierre's and Trousseau's syndromes, which are both rare conditions with advanced disease progression and poor clinical outcomes. Lemierre's syndrome may present with typical progressively infectious symptoms and signs, including sore throat, neck mass, and fever, whereas Trousseau's syndrome may present with thrombophlebitis and painful edema. Without antibiotic agents controlling the infection, the condition of patients with Lemierre's syndrome may progress to sepsis or septic shock. The infection pattern plays an important role for differential diagnosis. Herein, we describe the case of a 46-year-old woman presenting with atypical symptoms of Trousseau's syndrome mimicking Lemierre's syndrome. Laboratory analysis including protein C, protein S, rheumatoid factor, and antinuclear antibody ruled out hypercoagulopathy and autoimmune vasculitis. Abdominal computed tomography and panendoscopy revealed ulcerative tumor at the antrum. Pathological examination confirmed the presence of signet-ring cell adenocarcinoma. We highlight the clinical features and etiologies of internal jugular vein thrombosis, especially in Lemierre's syndrome and Trousseau's syndrome, to aid physicians in making an early diagnosis and providing timely management.

Extra-cardiac endovascular infections in the critically ill

Vascular infections are associated with high complication rates and mortality. While there is an extensive body of literature surrounding cardiac infections including endocarditis, this is less so the case for other endovascular infections. The objective of this narrative review is to summarize the epidemiology, clinical features, and selected management of severe vascular infections exclusive of those involving the heart. Endovascular infections may involve either the arterial or venous vasculature and may arise in native vessels or secondary to implanted devices. Management is complex and requires multi-disciplinary involvement from the outset. Infective arteritis or device-related arterial infection involves removal of the infected tissue or device. In cases where complete excision is not possible, prolonged courses of antimicrobials are required. Serious infections associated with the venous system include septic thrombophlebitis of the internal jugular and other deep veins, and intracranial/venous sinuses. Source control is of paramount importance in these cases with adjunctive antimicrobial therapy. The role of anticoagulation is controversial although recommended in the absence of contraindications. An improved understanding of the management of these infections, and thus improved patient outcomes, requires multi-center, international collaboration.

Lemierre syndrome caused by Klebsiella pneumoniae complicated by epidural abscess - Case report

Klebsiella pneumoniae is an extremely rare case of the Lemierre syndrome, which is characterized as septic thrombophlebitis of the jugular vein as a consequence of oropharyngeal infection. We present a unique case of Lemierre syndrome caused by Klebsiella pneumoniae, complicated by epidural abscess. The patient presented with fever, severe nuchal pain and stiffness and mild sore throat and headache. Computed tomography revealed a neck abscess localized dorsally to a left mandibular ramus and continuing caudally along the sternocleidomastoid muscle, thrombosis of the left internal jugular vein and fluid collection in the epidural space. Viewed under magnetic resonance imagining, the effusion had the character of an epidural abscess. Cultivation of oropharyngeal swab and blood cultures revealed Klebsiella pneumoniae. The neck abscess was surgically drained, and the patient was treated with a combination of parenteral antimicrobials until complete clinical and radiologic remission. This case highlights the importance of also covering the gram-negative facultative anaerobic rod spectrum in the empiric antimicrobial treatment of Lemierre syndrome.

Bilateral abducens nerve palsy due to septic thrombophlebitis

Purpose

To report a case of septic thrombophlebitis producing bilateral abducens nerve palsy.

Observation

A 65 year-old woman with recent sinus surgery experienced the onset of horizontal diplopia during treatment for bacteremia. Computer tomography of head and a neck ultrasonography showed right internal jugular vein occlusion. Ophthalmology examination was consistent with bilateral abducens nerve palsy. She was treated with systemic antibiotics and antiplatelet therapy with resolution of the internal jugular vein occlusion. The diplopia improved over a six-months.

Conclusion and importance

Our patient had Lemierre syndrome with an unusual presentation. The patient was treated for septic thrombophlebitis with a resolution of her ocular symptoms.

Torcular herophili and lateral sinus thrombosis: An atypical presentation of Lemièrre's syndrome

Lemièrre's syndrome (LS) is an uncommon disease characterized by septic thrombophlebitis of the jugular vein in the context of otorhinolaryngologic infections. These patients are often young and the pharyngotonsillar infection is the most frequent primary focus, but other foci like acute otitis media or otomastoiditis have been described. Although the internal jugular vein is the most commonly affected site, a few case reports have been published with thrombosis of other veins, such as the facial vein or transverse sinus. We report the case of a 93-year-old woman with an atypical presentation of LS presenting with thrombophlebitis of the internal jugular vein, transverse sinuses and Herophili torcula after an acute otitis media complicated with acute otomastoiditis. Infectious cerebral venous thrombosis (CVT) is rare and accounts for 6-12% of the total in large adult series and is usually associated to otorhinolaryngologic infections. CVT is an atypical presentation of LS that can be potentially lethal, especially during the acute phase. For this reason, clinical suspicion and early treatment are vital to improve the prognosis of these patients. Although surgical treatment is recommended in cases of LS complicated with CVT, conservative management with antibiotics and anticoagulation lead to ad integrum restitutio without neurological sequelae in our case, suggesting that surgical treatment may not be necessary in all cases of LS complicated with CVT.

Environmental Triggers of Autoreactive Responses: Induction of Antiphospholipid Antibody Formation

Antiphospholipid antibodies (aPLs) comprise a diverse family of autoantibodies targeted against proteins with the affinity toward negatively charged phospholipids or protein-phospholipid complexes. Their clinical significance, including prothrombotic potential of anti-cardiolipin antibodies (aCLs), anti-β2-glycoprotein I antibodies (aβ2-GPIs), and lupus anti-coagulant (LA), is well-established. However, the ontogeny of these pathogenic aPLs remains less clear. While transient appearance of aPLs could be induced by various environmental factors, in genetically predisposed individuals these factors may eventually lead to the development of the antiphospholipid syndrome (APS). Since the first description of APS, it has been found that a wide variety of microbial and viral agents influence aPLs production and contribute to clinical manifestations of APS. Many theories attempted to explain the pathogenic potential of different environmental factors as well as a phenomenon termed molecular mimicry between β2-GPI molecule and infection-relevant structures. In this review, we summarize and critically assess the pathogenic and non-pathogenic formation of aPLs and its contribution to the development of APS.

Methicillin-Resistant Staphylococcus aureus Septic Internal Jugular Thrombophlebitis: Updates in the Etiology and Treatment of Lemierre's Syndrome

BACKGROUND

Lemierre's syndrome is classically precipitated by oropharyngeal infections that progress to suppurative internal jugular vein thrombophlebitis via direct extension. Metastatic pneumonia from septic emboli is nearly universal and bacterial seeding frequently results in disseminated septic foci. Fusobacterium necrophorum is the most commonly reported etiologic agent, though methicillin-resistant Staphylococcus aureus (MRSA) is an emerging pathogen and a myriad of oropharyngeal flora must be covered until blood cultures return. Prompt identification is paramount to minimizing morbidity. Empiric treatment with antibiotics exhibiting predominantly anaerobic activity has been standard, but now may be insufficient, given an evolving microbial landscape. Anticoagulation continues to be debated.

CASE REPORT

We describe an uncommon presentation of Lemierre's syndrome in a diabetic patient secondary to MRSA, where the only identifiable source of entry was atraumatic post-auricular cellulitis. Why Should an Emergency Physician Be Aware of This? Given the evolving landscape of organisms implicated in septic internal jugular thrombophlebitis, empiric treatment should entail consideration of MRSA. Patients at an elevated risk include those who are undomiciled or incarcerated, injection drug users, human immunodeficiency virus-positive, and have recently been hospitalized or completed a course of antibiotics. The existing evidence evaluating empiric anticoagulation is low-powered and retrospective and would benefit from randomized controlled trials. Although it does not appear valuable for most, those with thrombus extension, persistent bacteremia, or central venous thrombosis may benefit.

Antibiotic and Anticoagulation Therapy in Lemierre's Syndrome: Case Report and Review

Lemierre's syndrome is a rare and fatal disease and is also known as the forgotten disease to describe the rarity of this syndrome in the antibiotic era. However, in the last 20 years, the incidence of this disease has been increasing. Authors report a case of Lemierre's syndrome with extensive venous thrombosis involving right internal jugular veins with extension to the sigmoid and lateral sinus and also review the literature on the use of anticoagulant therapy in Lemierre's syndrome. A computerized Medline study was carried out through the use of PUBMED: using the Medical Subject Headings terms 'Lemierre Syndrome/diagnosis' and words 'Lemierre's syndrome and anticoagulation'. From this, authors found 64 articles from 2002 to January 2018 with a total of 165 patients. The purpose of our review is to emphasize that antibiotic therapy should be started immediately, while anticoagulant therapy should be started in selected cases. Anticoagulation should be carried out in absence of any contraindication or presumed risk following clinical anticoagulation guidelines and only in patients with poor clinical response despite antibiotics therapy, predisposing thrombophilia and intracranial thrombosis.

Nontraumatic Vascular Emergencies of the Neck

Nontraumatic vascular emergencies of the head and neck are uncommon, but can occur in patients with central venous catheters, head and neck infections, and in patients with head and neck cancer. Recognizing the imaging findings of vascular complications in these patient populations is critically important to ensure expeditious treatment to avoid significant morbidity and mortality.

Rare and life-threatening complication after an attempted lower third molar extraction: Lemierre syndrome

Lemierre's syndrome is also known as the forgotten disease, and is a rare but life-threatening complication that can arise after surgical extractions of infected mandibular third molars. Owing to its rarity, oral and maxillofacial surgeons might not immediately recognise or can underestimate the pathological signs, and consequently do not apply the appropriate therapy to treat the syndrome. Here, we report on the occurrence and management of a case of Lemierre's syndrome, where the complications affected the right sigmoid sinus. Since the condition appear to be underreported and not properly highlighted, eventual systematic review and meta-analysis of the occurrence of the Lemierre's syndrome are highly recommended.

Fusobacterium Septicemia with Liver and Lung Abscesses Due to Diverticulitis

The Fusobacterium species is known for its association with septic thrombophlebitis of the internal jugular vein (Lemierre's syndrome). Lemierre's syndrome is associated with septic emboli to the liver and lungs, often causing multiple abscesses. We present a unique case of Fusobacterium septicemia in which the bacteria invaded the portal vein through the gastrointestinal mucosa due to diverticulitis and spread hematogenously to the liver and lungs, causing abscesses. It was treated successfully with 6 weeks of antibiotics. Physicians should be aware of this rare pathogen and suspect its presence in severe pharyngitis or culture-negative liver abscess.

Purpura fulminans with Lemierre's syndrome caused by Gemella bergeri and Eikenella corrodens: a case report

BACKGROUND

Gemella bergeri is one of the nine species of the genus Gemella and is relatively difficult to identify. We herein describe the first case of septic shock due to a Gemella bergeri coinfection with Eikenella corrodens.

CASE PRESENTATION

A 44-year-old Asian man with a medical history of IgG4-related ophthalmic disease who was prescribed corticosteroids (prednisolone) presented to our hospital with dyspnea. On arrival, he was in shock, and a purpuric eruption was noted on both legs. Contrast enhanced computed tomography showed fluid retention at the right maxillary sinus, left lung ground glass opacity, and bilateral lung irregular opacities without cavitation. Owing to suspected septic shock, fluid resuscitation and a high dose of vasopressors were started. In addition, meropenem, clindamycin, and vancomycin were administered. Repeat computed tomography confirmed left internal jugular and vertebral vein thrombosis. Following this, the patient was diagnosed with Lemierre's syndrome. Furthermore, he went into shock again on day 6 of hospitalization. Additional soft tissue infections were suspected; therefore, bilateral below the knee amputations were performed for source control. Cultures of the exudates from skin lesions and histopathological samples did not identify any pathogens, and histopathological findings showed arterial thrombosis; therefore it was concluded that the second time shock was associated with purpura fulminans. Following this, his general status improved. He was transferred to another hospital for rehabilitation. The blood culture isolates were identified as Gemella bergeri and Eikenella corrodens. Gemella bergeri was identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry and confirmed by 16S rRNA gene sequencing later. The primary focus of the infection was thought to be in the right maxillary sinus, because the resolution of the fluid retention was confirmed by repeat computed tomography.

CONCLUSIONS

Gemella bergeri can be the causative pathogen of septic shock. If this pathogen cannot be identified manually or through commercial phenotypic methods, 16S rRNA gene sequencing should be considered.

Lemierre's syndrome: a rare cause of sepsis presenting with an absence of throat symptoms

A 16-year-old boy presented to hospital with a 6-day history of diarrhoea, vomiting and abdominal pain. During his admission he was found to be hypotensive, tachycardic and persistently feverish. Blood cultures taken on admission isolated Fusobacterium necrophorum CT scanning of his neck showed a non-occlusive thrombus of the right internal jugular vein and a small right parapharyngeal abscess. CT scans of the chest and abdomen revealed multiple pulmonary abscesses, bilateral pleural effusions and splenomegaly. Treatment consisted of an unfractionated heparin infusion and intravenous antibiotics. A right-sided intercostal drain was inserted for a complex right-sided empyema. He subsequently developed a left-sided pleural effusion which was treated with a video-assisted thoracoscopic surgery (VATS) pleurodesis procedure. His fever resolved after his VATS pleurodesis procedure 3 weeks after initial presentation. Clinically he made a slow recovery but now is improved after 6 weeks of intravenous antibiotics and was discharged home.

Clinical Mimics: An Emergency Medicine-Focused Review of Streptococcal Pharyngitis Mimics

BACKGROUND

Pharyngitis is a common disease in the emergency department (ED). Despite a relatively low incidence of complications, there are many dangerous conditions that can mimic this disease and are essential for the emergency physician to consider.

OBJECTIVE

This article provides a review of the evaluation and management of group A β-hemolytic Streptococcal (GABHS) pharyngitis, as well as important medical conditions that can mimic this disease.

DISCUSSION

GABHS pharyngitis often presents with fever, sore throat, tonsillar exudates, and anterior cervical lymphadenopathy. History and physical examination are insufficient for the diagnosis. The Centor criteria or McIsaac score can help risk stratify patients for subsequent testing or treatment. Antibiotics may reduce symptom duration and suppurative complications, but the effect is small. Rheumatic fever is uncommon in developed countries, and shared decision making is recommended if antibiotics are used for this indication. Oral analgesics and topical anesthetics are important for symptom management. Physicians should consider alternate diagnoses that may mimic GABHS pharyngitis, which can include epiglottitis, infectious mononucleosis, Kawasaki disease, acute retroviral syndrome, Lemierre's syndrome, Ludwig's angina, peritonsillar abscess, retropharyngeal abscess, and viral pharyngitis. A focused history and physical examination can help differentiate these conditions.

CONCLUSIONS

GABHS may present similarly to other benign and potentially deadly diseases. Diagnosis and treatment of pharyngitis should be based on clinical evaluation. Consideration of pharyngitis mimics is important in the evaluation and management of ED patients.

The long shadow of lemierre's syndrome

Lemierre's syndrome is a rare and feared complication of pharyngitis, occurring most commonly in adolescents and young adults. It is typically defined by the constellation of septic internal jugular vein thrombophlebitis, pulmonary and other septic emboli, and sterilesite infection by Fusobacterium necrophorum. The rarity and severity of Lemierre's syndrome has made it an attractive subject for case reports but there is a paucity of evidence to inform areas of persistent uncertainty. In recent years, heightened attention and controversy has focused upon speculation that a purported rise in the incidence of Lemierre's syndrome is due to reduced antibiotic prescribing for respiratory tract infections, that F. necrophorum is an under-appreciated cause of acute tonsillopharyngitis and that testing and targeted treatment would prevent cases of Lemierre's syndrome.

A Case of Lemierre's Syndrome in Intensive Care Unit

We report a 21-year-old young male with Lemierre's syndrome presented as tonsillitis and Fusobacterium septicemia with respiratory failure and required intensive care. Lemierre's syndrome is the septic embolic complication of recent pharyngeal illness. Fusobacterium spp. accounts for the majority of cases. High index of suspicion is needed and prolonged antibiotic is advised. It is seldom seen in intensive care but should never be forgotten.

Characterization of Fusobacterium varium Fv113-g1 isolated from a patient with ulcerative colitis based on complete genome sequence and transcriptome analysis

Fusobacterium spp. present in the oral and gut flora is carcinogenic and is associated with the risk of pancreatic and colorectal cancers. Fusobacterium spp. is also implicated in a broad spectrum of human pathologies, including Crohn’s disease and ulcerative colitis (UC). Here we report the complete genome sequence of Fusobacterium varium Fv113-g1 (genome size, 3.96 Mb) isolated from a patient with UC. Comparative genome analyses totally suggested that Fv113-g1 is basically assigned as F. varium, in particular, it could be reclassified as notable F. varium subsp. similar to F. ulcerans because of partial shared orthologs. Compared with the genome sequences of F. varium ATCC 27725 (genome size, 3.30 Mb) and other strains of Fusobacterium spp., Fv113-g1 possesses many accessary pan-genome sequences with noteworthy multiple virulence factors, including 44 autotransporters (type V secretion system, T5SS) and 13 Fusobacterium adhesion (FadA) paralogs involved in potential mucosal inflammation. Indeed, transcriptome analysis demonstrated that Fv113-g1-specific accessary genes, such as multiple T5SS and fadA paralogs, showed notably increased expression with D-MEM cultivation than with brain heart infusion broth. This implied that growth condition may enhance the expression of such potential virulence factors, leading to remarkable survival against other gut microorganisms and to the pathogenicity to human intestinal epithelium.