Syndrome de Lemierre et grippe A(H1N1)

Lemierre Syndrome: A Diagnosis behind the Veil

Lemierre syndrome (LS) is a rare, serious infection that is often misdiagnosed, as it frequently mimics common upper respiratory infections. It is even rarer for LS to be preceded by a viral infection. We share a case of LS in a young man who presented to the Emergency Department with COVID-19 viral infection followed by a subsequent LS diagnosis. The patient's condition initially worsened despite treatments for COVID-19 and was subsequently started on broad-spectrum antibiotics. He was then diagnosed with LS after blood cultures grew Fusobacterium necrophorum, and antibiotics were adjusted accordingly, resulting in improvement of symptoms. Even though LS is often recognized as a sequela of bacterial pharyngitis, preceding viral infections, including COVID-19, might be a risk factor that contributes to the development of LS.

Venous thromboembolism in SARS-CoV-2 patients: only a problem in ventilated ICU patients, or is there more to it?

Venous thromboembolism (VTE) is a well-known complication in hospitalised patients [1–5]. Risk factors include older age, obesity, immobilisation, active malignancy, systemic inflammatory response syndrome (SIRS), (major) surgery, thrombophilia and a history of thromboembolism [2, 5]. In 1884, Rudolph Virchow first described the underlying pathophysiological mechanisms, which consist of endothelial cell dysfunction/inflammation, low blood flow and blood hypercoagulability. Current guidelines recommend the use of thromboprophylaxis in acutely ill medical patients who are at high risk for VTE (Padua score ≥4, IMPROVE (International Medical Prevention Registry on Venous Thromboembolism) score ≥2) [6]. However, in medical practice, less than half of the patients at risk receive adequate thromboprophylaxis [4].

Insidious venous thromboembolism (VTE) is mainly a problem in ICU-ventilated SARS-CoV-2 patients, while patients in the general ward, treated with thromboprophylaxis (0.5 mg·kg−1), had a low incidence of insidious VTE https://bit.ly/2Yl8jft

Lemierre's syndrome complicating influenza A virus infection

We report a 24‐year‐old previously healthy woman with Lemierre's syndrome following influenza A virus infection. One week after influenza A was diagnosed by rapid antigen test and treated by oseltamivir, she developed multiple cavitary lung lesions, and a left internal jugular vein thrombosis. The blood culture grew Fusobacterium necrophorum. We administered ampicillin‐sulbactam and unfractionated heparin to which she responded very well. Although viral infections have been related to Lemierre's syndrome, influenza virus rarely implicated. Lemierre's syndrome should be included in the differential diagnoses of rare complications of influenza virus infection.

Complicated Head and Neck Infections Following Influenza Virus Infection in Children

Seasonal influenza infection is associated with secondary bacterial complications involving the upper and lower respiratory tract. However, the association of influenza infection with secondary severe or complicated head and neck infections is not appreciated. We report 6 cases of head and neck infections following influenza infection in pediatric patients.

Use of Direct Hemoperfusion with Polymyxin B-Immobilized Fiber for the Treatment of Septic Shock Complicated with Lemierre Syndrome Caused by Fusobacterium necrophorum

We report a case of septic shock treated with PMX-DHP that was complicated with Lemierre syndrome caused by Fusobacterium necrophorum. The patient was a 31-year-old man who was initially diagnosed with influenza. He received treatment; however, because his symptoms gradually worsened, he was transported to our hospital 10 days following his diagnosis. His initial examination revealed symptoms of respiratory distress and an altered level of consciousness. Based on laboratory and imaging results, it became clear that he suffered from septic shock of unknown etiology, disseminated intravascular coagulation, and acute renal and respiratory failure. We initiated treatment with vasopressors, an antibacterial agent, immunoglobulins as well as an appropriate ventilator management; however, his unstable circulatory condition continued. As soon as PMX-DHP was initiated, 2 days following admission to the ICU, his circulatory instability normalized. F. necrophorum was ultimately detected after a culture examination, and contrast-enhanced computed tomography revealed a jugular vein thrombus, which led to the diagnosis of Lemierre syndrome. The patient's condition gradually improved, and he was discharged from the ICU after 19 days.

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.

To anticoagulate? Controversy in the management of thrombotic complications of head & neck infections

OBJECTIVE

To review the thrombotic complications of head and neck infections, including Lemierre's syndrome, and their management.

METHODS

A retrospective review of pediatric patients presenting to McMaster Children's Hospital from 2009 to 2013 was undertaken. The literature was reviewed for evidence regarding the use of anticoagulation therapy in this population.

RESULTS

Eleven cases (6 males, 5 females) were identified. The median age was 10.9 (range 14 months-17 years). The most frequent head and neck infection causing a thrombotic complication was mastoiditis (n = 6). All had thrombi identified on imaging, with the most common location being the sigmoid sinus (n = 6) followed by the internal jugular vein (n = 5). All 11 patients were anti-coagulated with low molecular weight heparin (LMWH) within a median of 2 days of diagnosis (average duration 105.8 days). Ten patients (90.9%) had thrombus improvement or resolution within a median of 3.4 months (range 1.0-13.9). Adverse sequelae from the thrombi were MCA infarct (n = 1), septic pulmonary emboli (n = 4), cranial nerve palsies (n = 3) and Horner's syndrome (n = 2). There were no adverse effects from anti-coagulation therapy. Review of the literature revealed anticoagulant use in 63.7% of pediatric cases reported since 2002.

CONCLUSION

Anticoagulation remains controversial in the management of thrombotic complications from head and neck infections. Based on this case series, certain recommendations can be made regarding the benefits of anticoagulation, which appear to outweigh the risks. Further research is required to establish evidence for consensus in the antithrombotic management of thrombotic sequelae of head and neck infections.