Lemierre's syndrome: more than a historical curiosa

Lemierre's syndrome due to community-acquired meticillin-resistant Staphylococcus aureus infection and presenting with orbital cellulitis: a case report

Introduction

Lemierre's syndrome is septic thrombophlebitis of the internal jugular vein leading to metastatic septic complications following an oropharyngeal infection. It is usually caused by the anaerobe, Fusobacterium necrophorum. Of late, meticillin-resistant Staphylococcus aureus is increasingly being recognised as a cause of community-acquired skin and soft tissue infections. We report a rare case of Lemierre's syndrome caused by community-acquired meticillin-resistant Staphylococcus aureus infection.

Case presentation

A previously healthy 16-year-old girl presented with fever of 13 days duration, painful swelling around the right eye and diplopia followed by the appearance of pulmonary infiltrates. Imaging studies confirmed the clinical suspicion of bilateral jugular venous thrombosis with septic pulmonary embolism. Meticillin-resistant Staphylococcus aureus was isolated on blood cultures. The hospital course was complicated by massive haemoptysis and pulmonary aspiration necessitating mechanical ventilation. The patient subsequently made a complete recovery.

Conclusion

Lemierre's syndrome, although rare, is a potentially lethal but treatable complication of head and neck sepsis. Early clinical recognition of Lemierre's syndrome and appropriate antibiotic treatment can be life-saving. One should consider the possibility of community-acquired meticillin-resistant Staphylococcus aureus infection in patients with suspected Lemierre's syndrome.

Embolia pulmonar séptica secundária à tromboflebite jugular: um caso de síndrome de Lemierre

A síndrome de Lemierre é caracterizada pela infecção aguda da orofaringe, complicada por trombose venosa jugular interna secundária à tromboflebite séptica, e por infecções metastáticas a vários órgãos distantes-mais freqüentemente os pulmões. Relatamos um caso de síndrome de Lemierre em uma mulher de 56 anos que se apresentou com massa cervical à direita e febre. Trombose venosa jugular interna foi demonstrada na ecografia. A tomografia computadorizada de tórax revelou múltiplas opacidades em ambos os pulmões. Uma biópsia pulmonar cirúrgica foi realizada por suspeita de metástases pulmonares. O exame anatomopatológico revelou êmbolos sépticos em parênquima pulmonar. Retrospectivamente, a paciente relatou história de faringite duas semanas antes da hospitalização. Após o diagnóstico, foi tratada com antibióticos de amplo espectro (cefuroxima por 7 dias e azitromicina por 5 dias e, posteriormente, devido à persistência de febre, cefepime por 7 dias). A tomografia computadorizada de tórax, realizada um mês após, mostrou resolução das opacidades.

Lemierre Syndrome: Two Preschool Children with Cerebral Infarcts

We report two children who developed hemiparesis secondary to cerebral infarcts complicating Lemierre syndrome. The first case is a one-year-old patient who presented a left internal jugular vein thrombosis and a left carotid compression due to retropharyngeal cellulitis. The second case is a five-year-old girl who presented a left internal jugular vein and a right carotid artery thrombosis associated with an oropharyngeal cellulitis. Etiologic agents involved were Staphylococus aureus in the first case and Fusobacterium necrophorum in the second case.

These cases call for vigilance among physicians for this rare syndrome, its unusual presentation and its associated severe complications.

A previously healthy 15-year-old girl with high fever and progressive dyspnoea

A 15-year-old girl was admitted with a high fever and progressive malaise, vomiting, anorexia and abdominal complaints. She previously had a sore throat and unilateral painful swollen lymph nodes in the neck. Laboratory investigation indicated a bacterial infection. Blood cultures were taken. There was infiltrate in the left lung. Pneumonia complicated with sepsis was suspected and ceftriaxone was started. The patient's condition deteriorated. Computed tomography (CT) scan showed progressive infiltrates in both lungs and pleural effusion. Blood culture led to the diagnosis. After changing antibiotics the patient slowly improved. Antibiotics were continued for several weeks.

Fatal delayed post-operative cerebral venous thrombosis after excision of hypoglossal nerve schwannoma

Lower cranial nerve schwannomas are rare tumours. We present a 35 year old female patient who had a lower cranial nerve schwannoma with both intracranial and extracranial components. The internal jugular vein was injured during the dissection of the extracranial portion of the tumour. Ligation of the internal jugular vein is not associated with significant post-operative complications. Our patient however, developed retrograde cortical venous thrombosis on the 14(th) post-operative day resulting in multiple areas of haemorrhagic venous infarction with raised intracranial pressure. Such a delayed contiguous cortical venous thrombosis has not been reported. We present this report to highlight this event and to outline the probable causes for the same.

Human Fusobacterium necrophorum strains have a leukotoxin gene and exhibit leukotoxic activity

Fusobacterium necrophorum, a Gram-negative anaerobe, causes a variety of necrotic infections in humans and animals. There are two subspecies: subsp. necrophorum and subsp. funduliforme. In cattle, subsp. necrophorum is more prevalent and production of leukotoxin is a major virulence factor. The leukotoxin operon (lktBAC) consists of three genes, lktB, lktA and lktC, of which lktA is the structural toxin gene. The subspecies identity of human F. necrophorum is less certain and it is not known whether human strains possess the leukotoxin gene or leukotoxin activity. Therefore, the objective of this study was to identify the subspecies status of four human clinical strains of F. necrophorum and determine whether they have the leukotoxin gene or leukotoxin activity. Phenotypic and genotypic characteristics suggested that the four strains belonged to subsp. funduliforme, which was confirmed by sequencing the 16S rRNA gene. Analysis of the four strains by PCR revealed the presence of the leukotoxin operon. Partial DNA sequencing identified one human strain with full-length lktA, whereas the others exhibited considerable heterogeneity in size. All strains had a leukotoxin operon promoter-containing intergenic region similar to that of bovine subsp. funduliforme strains, which was confirmed by DNA sequencing and Southern blotting. Despite variations in the lktA gene, all strains secreted leukotoxin as demonstrated by Western blotting. Flow cytometry assays revealed that the leukotoxin was toxic to human white blood cells. In conclusion, the human strains examined contained a leukotoxin gene whose gene product was biologically active. The importance of leukotoxin as a virulence factor in human fusobacterial infections needs further evaluation.

Lemierre's syndrome and other disseminated Fusobacterium necrophorum infections in Denmark: a prospective epidemiological and clinical survey

In a 3-year prospective study, all cases of disseminated Fusobacterium necrophorum infections found in Denmark from 1998 to 2001 were analysed, with the aim of describing the epidemiology and clinical features of the variants of Lemierre’s syndrome and disseminated non-head-and-neck-associated F. necrophorum infections. Fifty-eight cases of Lemierre’s syndrome were reported in previously healthy persons, with an incidence of 14.4 cases per million per year in youngsters aged 15–24 years old. There was no increase during the study period. Lemierre’s syndrome originating from an oropharyngeal infection was seen in 37 youngsters. An otogenic variant of Lemierre’s syndrome was seen in 5 children with dissemination to nearby regions, and other variants of Lemierre’s syndrome, e.g. from the sinuses and teeth, were seen in 16 adults. Patients often had metastatic infections already on admission and needed prolonged hospitalisation. The overall mortality of Lemierre’s syndrome was 9%. Forty-two elderly patients had disseminated F. necrophorum infections originating from foci in lower parts of the body. They frequently had predisposing diseases, e.g. abdominal or urogenital cancers, which contributed to the high mortality of 26%. This study shows that the incidence of Lemierre’s syndrome is higher than that previously found and has a characteristic age distribution. Early suspicion of the diagnosis, several weeks of antibiotic therapy, often combined with surgical drainage, is mandatory to lower the mortality. In disseminated non-head-and-neck-associated F. necrophorum infections, underlying cancers must be considered.

Methicillin-resistant Staphylococcus aureus as a cause of extensive retropharyngeal abscess in two infants

We report 2 cases of extensive methicillin-resistant Staphylococcus aureus (MRSA) retropharyngeal abscesses in young infants. In 1 case, the abscess was associated with a reactive thrombosis of the jugular vein. Based on the existing literature and the rapid emergence of MRSA skin and soft tissue infections, it is possible that similar severe infections will occur with increasing frequency in young infants.

Human infection with Fusobacterium necrophorum (Necrobacillosis), with a focus on Lemierre's syndrome

Human infection with Fusobacterium necrophorum usually involves F. necrophorum subsp. funduliforme rather than F. necrophorum subsp. necrophorum, which is a common pathogen in animals. Lemierre's syndrome, or postanginal sepsis, is the most common life-threatening manifestation. Tonsillitis is followed by septic thrombophlebitis of the internal jugular vein and then a septicemia with septic emboli in lungs and other sites. Recent evidence suggests that F. necrophorum can be limited to the throat and cause persistent or recurrent tonsillitis. F. necrophorum is unique among non-spore-forming anaerobes, first for its virulence and association with Lemierre's syndrome as a monomicrobial infection and second because it seems probable that it is an exogenously acquired infection. The source of infection is unclear; suggestions include acquisition from animals or human-to-human transmission. Approximately 10% of published cases are associated with infectious mononucleosis, which may facilitate invasion. Recent work suggests that underlying thrombophilia may predispose to internal jugular vein thrombophlebitis. Lemierre's syndrome was relatively common in the preantibiotic era but seemed to virtually disappear with widespread use of antibiotics for upper respiratory tract infection. In the last 15 years there has been a rise in incidence, possibly related to restriction in antibiotic use for sore throat.

Microbiologic investigations for head and neck infections

A variety of methods, including direct examination of stained smears, antigen detection, routine and special cultures, and histopathologic evaluation are available for investigation of head and neck infections. Newer rapid molecular techniques with increased sensitivity and specificity are becoming available at many centers. Evaluation of specific causes in head and neck infections is complicated by the tendency for polymicrobial infections, difficulty in obtaining adequate specimens, and the presence of a diverse endogenous microflora at various mucosal sites that also can include true pathogens. These aspects of laboratory investigation for head and neck infections are reviewed in this article.

Lemierre syndrome complicated by cavernous sinus thrombosis, the development of subdural empyemas, and internal carotid artery narrowing without cerebral infarction. Case report

Lemierre syndrome is an extremely rare complication of mild-to-moderate pharyngeal infections. The authors present an unusual case of Lemierre syndrome in a 16-year-old boy with cavernous sinus thrombosis and right internal carotid artery narrowing without neurological sequelae, right subdural empyema, and cerebritis in the right temporal and occipital lobes. Neuroimaging also demonstrated right jugular vein thrombosis. Cultures of samples from the blood proved positive for the presence of Fusobacterium necrophorum. The patient underwent unilateral tonsillectomy, drainage of the peritonsillar abscess, and a myringotomy on the right side. Postoperatively the patient was treated conservatively with antibiotic therapy resulting in an excellent outcome.

Septic pulmonary emboli due to periodontal disease

Septic pulmonary embolization (SPE) is a rare but serious disorder. It is a well-recognized potential problem in the settings of tricuspid valve endocarditis, septic thrombophlebitis, infected central venous catheters, and postanginal septicemia. Less well documented is the occurrence of SPE in patients with periodontal disease without suppurative thrombophlebitis of the great vessels of the neck. We report a patient with SPE in whom periodontal disease was the only identifiable nidus of infection and review the literature regarding the four other patients reported to have suffered this complication.

Lemierre’s syndrome

We report a case of Lemierre’s syndrome complicated by an epidural abscess. This manifestation of Lemierre’s syndrome has not been described previously.

[Lemierre syndrome variant: Hepatic abscesses and hepatic venous thrombosis due to Fusobacterium nucleatum septicemia]

INTRODUCTION

Like Fusobacterium necrophorum, Fusobacterium nucleatum is capable causing Lemierre's syndrome. Various locations of venous thrombosis have been described associated with Fusobacterium sp. septicemia.

EXEGESIS

We describe a 43-year old alcoholic patient with F.nucleatum septicemia complicated with hepatic abscesses, middle hepatic venous thrombosis, osteomyelitis and infiltrative pneumonia. A pancreatic prosthesis was the only potentially identified infectious entrance.

CONCLUSION

Our patient showed an alternative presentation of Lemierre's syndrome, a "digestive variant". To the best of our knowledge, this is the first report of Fusobacterium septicemia associated with hepatic venous thrombosis. This report is close to the cases of portal thrombosis and opens the clinical sphere of the lemierre's syndrome, whose incidence is increasing.

A young adult patient with septic pulmonary emboli of undetermined origin

A 25-year-old male who had no significant medical history presented abrupt onset of high-grade fever and chills without noticeable trigger. The patient sought for medical attention for subsequently developed dyspnea and chest pain. Radiological examinations revealed bilateral lung peripheral multiple opacities, some of which were cavitating, suggesting of septic pulmonary emboli (SPE). Isolation of Staphylococcus aureus in blood and sputum culture confirmed the diagnosis. Extensive examinations disclosed neither underlying immunocompromising conditions nor infectious foci, which are usually notable in patients with SPE. The present patient illustrates that there are patients with SPE in whom underlying conditions or infectious foci are difficult to determine, and that suspicion of the disease based on characteristic radiological findings is critical for appropriate management in those patients.

The leukotoxin operon of Fusobacterium necrophorum is not present in other species of Fusobacterium

The complete nucleotide sequence of the leukotoxin operon of Fusobacterium necrophorum has been determined. The operon consists of three genes (lktBAC) of which the leukotoxin structural gene is the middle determinant. Southern and western blot analyses and flow cytometry analysis for biological activity of the culture supernatants were carried out to determine if the leukotoxin is present in other species of the genus Fusobacterium. Only the two subspecies of F. necrophorum were found to possess the leukotoxin locus and produce the toxin. The human periodontal pathogen, F. nucleatum does not produce detectable leukotoxin. The F. necrophorum leukotoxin was found to be active against human neutrophils.