Lemierre Syndrome and Descending Necrotizing Mediastinitis Following Dental Extraction

Poorly controlled diabetes mellitus is strongly associated with descending necrotizing mediastinitis of odontogenic origin

OBJECTIVE

We hypothesized that poorly controlled diabetic status may be a negative prognostic factor for acute mediastinitis of odontogenic origin, and we conducted a cohort study to verify this hypothesis.

STUDY DESIGN

Data were collected on all consecutive patients diagnosed with maxillofacial infections of odontogenic origin who received surgical treatment in the Oral and Maxillofacial Surgery Department. All patients included in the study were divided into 4 groups based on the presence or absence of diabetes and mediastinitis. Poorly controlled diabetic status constituted our primary predictor variable, and the occurrence of descending necrotizing mediastinitis was the outcome variable.

RESULTS

All 7 patients with poorly controlled diabetes mellitus were complicated with descending necrotizing mediastinitis. An exact Fischer test was conducted to investigate the association of poorly controlled diabetes mellitus with descending necrotizing mediastinitis in patients admitted for surgical treatment of their maxillofacial collection. The result was significant at P < .01.

CONCLUSION

This study represents the first scientific attempt to associate poorly controlled diabetes mellitus with descending necrotizing mediastinitis of odontogenic origin. Our results show evidently that these patients are more susceptible to deep space infections, which subsequently spread faster and are much more difficult to control.

Significant rise in neck infections progressing to descending necrotizing mediastinitis during the COVID-19 pandemic quarantine

To present five patients with DNM, who were treated during the first quarantine for Coronavirus disease 2019 (Covid-19). Five patients with DNM were treated in our department during the first lockdown. The mean age of the patients was 42,2 years and four were male. Two patients were immunocompromised. Repeated surgical drainage was performed in all patients, whereas four were also subjected to elective tracheostomy during their first operation. The mean hospitalization duration was 55,4 days and mortality was 40%. During the first lockdown for the Covid-19, a rise in the ratio of DNM cases to the overall incidence of cervicofacial infections was observed in our department. All patients with DNM were operated on an emergency basis and were subsequently admitted to the ICU. We consider the effect of the quarantine as a decisive factor for this escalation, because according to the department archives, there had not been any cases of DNM originating from a dental infection, for the past 5 years. Additionally, past studies from the same department reported no more than 6 cases over a 10 year period.

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.

Cavernous sinus thrombosis caused by Streptococcus constellatus-associated Lemierre syndrome presenting as an isolated abducens nerve palsy

Purpose

To describe a patient with Streptococcus constellatus-associated Lemierre syndrome complicated by eventual cavernous sinus thrombosis (CST) that manifested as an isolated abducens nerve palsy.

Observations

A patient with a history of heavy alcohol use presented with Lemierre syndrome caused by an odontogenic infection due to Streptococcus constellatus. Despite initiation of intravenous antibiotics and eventual eradication of her bacteremia, she developed an isolated abducens nerve palsy on hospital day 7 due to associated CST.

Conclusions and Importance

CST is a rare complication of odontogenic infection and Lemierre syndrome. This case demonstrates the potential for primary odontogenic infections to progress to life- and sight-threatening diseases. This case also illustrates the importance of considering uncommon pathogens as the etiology of CST based on the suspected source of primary infection.

Lemierre's syndrome from odontogenic infection: Review of the literature and case description

Lemierre's syndrome (LS) is a rare potentially fatal sequel of head and neck infection, classically described as thrombophlebitis of the internal jugular vein (IJV) with cervical space infection extending into the thorax. Our objective was to answer the clinical question: "Does Lemierre syndrome (LS) from odontogenic infection differ from nonodontogenic LS in regard to clinical sequence, treatment, and survival." We reviewed the literature on the management of LS over the last two decades, with a focus on LS from odontogenic infection. Such a case is presented in order to portray the clinical sequence. Only 10 cases met the inclusion criteria (including the case presented). The recorded data were analyzed in comparison to large case series reviewing LS. Our data reflect the moderate differences in regard to IJV thrombosis and bacteriogram. There is an overall rise in published LS cases in the last 20 years. Odontogenic infection leading to LS is scarce, yet with survival rates similar to nonodontogenic LS. Repeated surgical interventions and aggressive wide spectrum antibiotic therapy remain the treatment of choice.

Descending Necrotizing Mediastinitis Treated with Tooth Extractions following Mediastinal and Cervical Drainage

Descending necrotizing mediastinitis (DNM) is a rare condition in which oropharyngeal infection spreads to the mediastinum via the cervical fascia. Delayed diagnosis and surgery result in a high mortality rate among patients with DNM. We present a case of DNM resulting from odontogenic infection treated successfully with tooth extraction following mediastinal and cervical drainage. A 43-year-old, previously healthy Japanese man was admitted to our hospital for treatment of acute mediastinitis. Computed tomography revealed gas collection around the mid-thoracic esophagus and bilateral pleural effusion. We performed mediastinal drainage via right thoracotomy. Cervicotomy was performed on postoperative day 14 to drain a residual cervical abscess. The patient required the extraction of ten teeth over three procedures to address primary odontogenic infection before his fever resolved on postoperative day 40. Prompt diagnosis, aggressive drainage and removal of the source of infection can improve survival among patients with this life-threatening disease.

Lemierre's syndrome due to intratumoral abscess of the uvula

Lemierre’s syndrome (LS), described in detail in 1936, used to be a life-threatening entity until the advent of antibiotics. Tonsillitis or pharyngitis are the main primary infections and oropharyngeal anaerobic flora is the predominant etiology. However, other primary site infections, as well as other microbiological agents have been reported since the first description. Inflammatory symptoms in the neck and marked findings on physical examination predominate the majority of cases. Nonetheless, the authors report the case of a 54-year-old man with a history of dysphagia followed by cough, purulent expectoration, and fever. The bad condition of his dentition was noteworthy. During the diagnostic work-up, an ulcerated lesion in the uvula and a middle lobe pneumonia were disclosed. Streptococcus viridans was isolated from blood culture. On the fifth day of hospitalization, the patient died after a copious episode of hemoptysis. The autopsy findings depicted an abscess within a squamous cell carcinoma of the uvula, pharyngitis with carotid sheath spreading accompanied by pylephlebitis and thrombosis of the internal jugular vein up to the innominate vein, surrounded by an abscess in the mediastinum. Alveolar hemorrhage and pneumonia were also present. We conclude that the ulcerated carcinoma of the uvula housed an abscess, facilitated by the poor oral hygiene, which triggered LS and the descending mediastinitis. Pulmonary involvement was due to the septic embolism from the internal jugular vein. We would like to highlight the uvula abscess as the primary site of infection in this case of LS with S. viridans as the causative agent.

A case report of Lemierre's Syndrome associated with dental sepsis

INTRODUCTION

Lemierre's syndrome is a potentially fatal condition characterised by spread of an oropharyngeal infection, resulting in thrombosis of the internal jugular vein. This leads to septicaemia and possible metastatic abscesses.

CASE PRESENTATION

We discuss the case of a previously healthy 17-year-old male who developed Lemierre's syndrome following dental sepsis. He presented with bilateral submandibular and submental swelling extending into the neck and chest. His management included a tracheostomy; incision and drainage of the abscesses; drainage of a pleural effusion and prolonged anticoagulant therapy.

CONCLUSION

The incidence of Lemierre's disease appears to be increasing and early diagnosis is essential. A high index of suspicion is needed in cases of oropharyngeal infection followed by fever, tender swelling of the neck and dysphagia - especially in young patients.