Human necrobacillosis, with emphasis on Lemierre's syndrome

A Case of Lemierre-Like Syndrome in a Pediatric Patient

Lemierre-like syndrome is a rare, systemic sequelae following a persistent oropharyngeal infection, leading to septic thrombophlebitis of the internal jugular vein (IJV). Lemierre syndrome is caused by the obligate anaerobic organism Fusobacterium necrophorum, innate to the oropharyngeal tract. Lemierre-like syndrome is due to infections caused by other organisms, including methicillin-resistant Staphylococcus aureus (MRSA). We are reporting a case of a five-month-old male who presented with one week of fever that was not alleviated by acetaminophen, bilateral otitis media, and left-sided cervical lymphadenopathy not alleviated with medical therapy. The patient's clinical course continued to deteriorate as he developed respiratory distress that progressed to acute respiratory failure requiring mechanical ventilation support. Extensive laboratory investigation ruled out the causes of primary and secondary immunodeficiencies. Blood cultures were positive for MRSA, and he was treated initially with vancomycin, then switched to linezolid per ENT recommendations, and ultimately needed daptomycin and ceftaroline therapy. A computed tomography (CT) scan of the neck and chest showed deep neck space infection, bilateral loculated pleural empyema, and mediastinitis. The patient required a decortication video-assisted thoracoscopic surgery (VATS), multiple drains, and a mediastinal washout to control the MRSA infection. This report emphasizes that the rapid progression and spread of septic thrombus can become detrimental to a patient's recovery and survival; therefore, it should be recognized early and treated promptly.

Genomic and phylogenomic analysis of Fusobacteriaceae family and proposal to reclassify Fusobacterium naviforme Jungano 1909 into a novel genus as Zandiella naviformis gen. nov., comb. nov. and reclassification of Fusobacterium necrophorum subsp. funduliforme as later heterotypic synonym of Fusobacterium necrophorum subsp. necrophorum and Fusobacterium equinum as later heterotypic synonym of Fusobacterium gonidiaformans

The family Fusobacteriaceae is a large family within the phylum Fusobacteriota. The reclassification of F. naviforme as Zandiella naviformis gen. nov., comb. nov. is proposed because of the separate and distinct phylogenetic situation on the basis of the results of 16S rRNA gene sequence analysis, the genetic and genomic differences from all other species and subspecies in the Fusobacteriaceae family. The type strain is ATCC 25832; CCUG 50052; NCTC 13121. In phylogenetic trees drawn using complete genome sequences and 16S rRNA gene sequences, F. necrophorum subsp. funduliforme and F. equinum were clades together with F. necrophorum subsp. necrophorum and F. gonidiaformans, respectively. The average nucleotide identity, average amino acid identity, and digital DNA-DNA hybridization values between themes exceeded the cut-off values for species delineation. Based on these results, F. necrophorum subsp. funduliforme and F. equinum should be reclassified as later heterotypic synonyms of F. necrophorum subsp. necrophorum and F. gonidiaformans, respectively.

Lemierre Syndrome: Report of a Case with an Innovative Diagnostic Method and Literature Review

Objective

To understand the clinical features, diagnosis and treatment of Lemierre syndrome (LS), a high-risk and low-prevalence infectious disease.

Methods

We present the severe LS case that was diagnosed using metagenomic next-generation sequencing (mNGS) in our hospital, and systematically summarized the diagnosis and treatment strategies of patients that reported LS from 2006 to 2022.

Results

The 24-year-old patient in our hospital suffered from cranial nerve paralysis, a neurological complication rarely seen in LS cases. The causative agent (Fusobacterium necrophorum, Fn) of this patient was only detected by mNGS tests, and the reads number of Fn detected by plasma mNGS tests was decrease as the patients gradually improved, indicating plasma mNGS is valuable in monitoring treatment efficacy. Although most of the cases retrieved from the literature showed typical symptoms, such as a history of sore throat, septic emboli, and internal jugular vein thrombosis, clinical manifestations were still relatively heterogeneous (eg, diversity of predisposing factors and pathogens, differences in pulmonary imaging features).

Conclusion

We summarized the clinical presentation, diagnosis, treatment, and regression of 17 symptomatic cases reported LS to provide clinicians with knowledge about this rare but fatal disease. mNGS assays should be considered as early as possible to identify the responsible pathogens for acute and critically ill patients with suspected infections in order to implement accurate and effective treatment.

Septic thrombophlebitis of portal and splenic vein secondary to Fusobacterium nucleatum: A case report of an abdominal variant of lemierre syndrome

RATIONALE

Septic thrombophlebitis of the internal jugular vein also known as Lemierre syndrome occurs secondary to an oropharyngeal infection often leading to septic embolisms to distant sites. Anaerobic gram-negative bacillus, Fusobacterium nucleatum and Fusobacterium necrophorum are commonly isolated organisms. Fusobacterium species has also been reported to complicate an intra-abdominal infection leading to septic thrombophlebitis of portal vein also known as pylephlebitis or abdominal variant of lemierre syndrome.

PATIENT CONCERNS

The patient was a middle-aged female patient with chief complaints of abdominal discomfort, intermittent fever and vomiting for one month.

DIAGNOSES

The final diagnosis was septic thrombophlebitis of portal and splenic vein secondary to Fusobacterium nucleatum.

INTERVENTIONS

Patient was managed with broad spectrum intravenous antibiotics with coverage against gram-negative bacilli, anaerobes, and aerobic streptococcus species with therapeutic anticoagulation.

OUTCOMES

Patient gradually improved and was discharged on oral apixaban. She was instructed to follow up with gastrointestinal specialist upon discharge in anticipation of the need for liver transplant in future.

LESSONS

Due to its high mortality and associated long term disease morbidity, clinicians should always strive towards early diagnosis and treatment of the condition with involvement of multidisciplinary teams.

Lemierre's Syndrome in the 21st Century: A Literature Review

Lemierre's syndrome is a rare, life-threatening complication of an acute oropharyngeal infection. It is generally characterised by pharyngitis secondary to Fusobacterium necrophorum, causing thrombophlebitis of the internal jugular vein and sepsis, with subsequent formation of septic emboli that can rapidly spread to different organ sites. The condition is associated with high mortality if treatment with antibiotics is delayed, and recent evidence suggests that patients are at significant risk of in-hospital morbidity and long-term neurological sequelae. Although it is agreed that antibiotics are the mainstay of treatment, there is currently no consensus on the use of anticoagulation in the condition. This review article aims to summarise our current understanding of Lemierre's syndrome with regard to its definition, epidemiology, microbiology, presentation, diagnosis, and treatment.

Lemierre's Syndrome (LS) Complicated by Cranial Nerve XII Palsy

Lemierre's syndrome (LS) is a rare medical condition that involves an acute oropharyngeal infection leading to septic thrombophlebitis of the internal jugular vein with embolic spread to organs like the kidneys, lungs, and large joints. Only very little literature has reported central nervous system involvement with LS. This is a case of 34-year-old woman with right-sided neck pain, swallowing difficulties, and a sore throat of 3 days duration at the time of presentation. CT of the neck with contrast showed a ruptured right peritonsillar abscess and thrombus in the right internal jugular vein suspicious of thrombophlebitis. The patient was managed for LS with IV antibiotics and anticoagulation. However, her clinical course was complicated by cranial nerve XII palsy, which is an extremely rare manifestation of LS.

Forget-me-not: Lemierre's syndrome, a case report

Background: Familiarity breeds complacency. One case of sore throat can start to sound like another. However, even common viral and bacterial infections can lead to serious sequelae. Clinicians cannot make a diagnosis if they do not consider it in their differential.Case: The presentation - and subsequent hospitalization - of a septic 19 year-old male college student is described. Despite brief interval improvement, he became hypoxic one week after developing a sore throat and was ultimately diagnosed with Lemierre's syndrome (septic thrombophlebitis of the internal jugular vein) via blood cultures and advanced imaging.Conclusions: Though rare, Lemierre's syndrome carries a high mortality rate. It should be considered an emergent complication of head and neck infections, particularly in young adults.

Comparative Genomic Analysis of Fusobacterium necrophorum Provides Insights into Conserved Virulence Genes

Fusobacterium necrophorum is a Gram-negative, filamentous anaerobe prevalent in the mucosal flora of animals and humans. It causes necrotic infections in cattle, resulting in a substantial economic impact on the cattle industry. Although infection severity and management differ within F. necrophorum species, little is known about F. necrophorum speciation and the genetic virulence determinants between strains. To characterize the clinical isolates, we performed whole-genome sequencing of four bovine isolates (8L1, 212, B17, and SM1216) and one human isolate (MK12). To determine the phylogenetic relationship and evolution pattern and investigate the presence of antimicrobial resistance genes (ARGs) and potential virulence genes of F. necrophorum, we also performed comparative genomics with publicly available Fusobacterium genomes. Using up-to-date bacterial core gene (UBCG) set analysis, we uncovered distinct Fusobacterium species and F. necrophorum subspecies clades. Pangenome analyses revealed a high level of diversity among Fusobacterium strains down to species levels. The output also identified 14 and 26 genes specific to F. necrophorum subsp. necrophorum and F. necrophorum subsp. funduliforme, respectively, which could be essential for bacterial survival under different environmental conditions. ClonalFrameML-based recombination analysis suggested that extensive recombination among accessory genes led to species divergence. Furthermore, the only strain of F. necrophorum with ARGs was F. necrophorum subsp. funduliforme B35, with acquired macrolide and tetracycline resistance genes. Our custom search revealed common virulence genes, including toxins, adhesion proteins, outer membrane proteins, cell envelope, type IV secretion system, ABC (ATP-binding cassette) transporters, and transporter proteins. A focused study on these genes could help identify major virulence genes and inform effective vaccination strategies against fusobacterial infections. IMPORTANCE Fusobacterium necrophorum is an anaerobic bacterium that causes liver abscesses in cattle with an annual incidence rate of 10% to 20%, resulting in a substantial economic impact on the cattle industry. The lack of definite biochemical tests makes it difficult to distinguish F. necrophorum subspecies phenotypically, where genomic characterization plays a significant role. However, due to the lack of a good reference genome for comparison, F. necrophorum subspecies-level identification represents a significant challenge. To overcome this challenge, we used comparative genomics to validate clinical test strains for subspecies-level identification. The findings of our study help predict specific clades of previously uncharacterized strains of F. necrophorum. Our study identifies both general and subspecies-specific virulence genes through a custom search-based analysis. The virulence genes identified in this study can be the focus of future studies aimed at evaluating their potential as vaccine targets to prevent fusobacterial infections in cattle.

Atypical presentation of Lemierre syndrome in a young healthy man with acute jaundice

This report presents a case of Lemierre syndrome caused by Fusobacterium necrophorum in a healthy young adult who presented atypically with shortness of breath and jaundice but no clinical or diagnostic evidence of thrombophlebitis. Due to this unusual presentation with jaundice, diagnosis was challenging and delayed. However, the patient was successfully initiated on a prolonged course of intravenous antibiotics; he required a period in the intensive care unit and was discharged without significant complications. This report aims to raise awareness of the diagnosis and treatment of this rare condition and to highlight both common and unusual presentations of the syndrome.

An Unusual Etiology of Lemierre-Like Syndrome: Preseptal Cellulitis due to Methicillin-Resistant Staphylococcus aureus

Lemierre’s syndrome (LS) is a rare and potentially fatal condition that predominantly affects young adults with oropharyngeal infection. Fusobacterium necrophorum is the usual etiology and classically causes internal jugular vein septic thrombophlebitis, frequently complicated by septic emboli to several organs (most classically to the lungs). Lemierre-like syndrome (LLS) describes the same constellation of symptoms and pathophysiology as Lemierre’s syndrome; however, Fusobacterium spp. are not the cause, and the source of infection may be nonoropharyngeal. We present a case with an unusual etiology of LLS: a patient with untreated preseptal cellulitis and associated methicillin-resistant Staphylococcus aureus (MRSA) bacteremia in the setting of injection drug use. Physical exam revealed tachypnea and rhonchi with severe periorbital and bilateral eyelid edema. Imaging demonstrated bilateral preseptal and orbital cellulitis with thrombosis of both internal jugular veins and bilateral pulmonary cavitary lesions consistent with septic pulmonary emboli. She was managed with anticoagulation and parenteral antibiotics. To our knowledge, this is the first case of LLS originating from preseptal cellulitis without evidence of preceding pharyngitis. While facial and orbital infections are rare etiologies of LLS, the potentially devastating sequelae of LLS warrant its inclusion in differential diagnoses.

Lemierre's syndrome with isolated external jugular vein thrombosis caused by Streptococcus intermedius

An 85-year-old woman with a history of rheumatoid arthritis fell due to unsteadiness and visited our emergency room due to head injury. The patient had minor head trauma and lip and oral cavity injuries, and she presented with fever. Laboratory tests showed high inflammatory marker levels. Moreover, there were indicative of urinary tract infection. Thus, the patient was admitted to our hospital. Blood cultures performed upon admission revealed the presence of Streptococcus intermedius, and contrast-enhanced computed tomography scan showed solitary right external jugular vein thrombosis and multiple abscesses in both lungs. Hence, the patient was diagnosed with Lemierre’s syndrome, and antimicrobial agents and anticoagulants were administered. The patient developed left pleurisy due to inflammation caused by lung abscesses, which improved with thoracic drainage. Her condition improved satisfactorily, and she was then discharged. There are only few studies about Lemierre’s syndrome caused by S. intermedius and even lesser cases involving external jugular vein thrombosis. Herein, we report a relatively rare case of Lemierre’s syndrome with isolated external jugular vein thrombosis.

Factors Affecting Patients with Concurrent Deep Neck Infection and Lemierre's Syndrome

Deep neck infection (DNI) is a severe disease affecting the deep neck spaces, and is associated with an increased risk of airway obstruction. Lemierre’s syndrome (LS) refers to septic thrombophlebitis of the internal jugular vein after pharyngeal infection, and is linked with high morbidity and mortality. Both diseases begin with an oropharyngeal infection, and concurrence is possible. However, no studies have examined the risk factors associated with co-existence of LS and DNI. Accordingly, this study examined a patient population to investigate the risk factors associated with concurrent DNI and LS. We examined data from a total of 592 patients with DNI who were hospitalized between May 2016 and January 2022. Among these patients, 14 had concurrent DNI and LS. The relevant clinical variables were assessed. In a univariate analysis, C-reactive protein (odds ratio (OR) = 1.004, 95% CI: 1.000−1.009, p = 0.045), involvement of multiple spaces (OR = 23.12, 95% CI: 3.003−178.7, p = 0.002), involvement of the carotid space (OR = 179.6, 95% CI: 22.90−1409, p < 0.001), involvement of the posterior cervical space (OR = 42.60, 95% CI: 12.45−145.6, p < 0.001) and Fusobacterium necrophorum (F. necrophorum, OR = 288.0, 95% CI: 50.58−1639, p < 0.001) were significant risk factors for concurrent DNI and LS. In a multivariate analysis, involvement of the carotid space (OR = 94.37, 95% CI: 9.578−929.9, p < 0.001), that of the posterior cervical space (OR = 24.99, 95% CI: 2.888−216.3, p = 0.003), and F. necrophorum (OR = 156.6, 95% CI: 7.072−3469, p = 0.001) were significant independent risk factors for concurrent LS in patients with DNI. The length of hospitalization in patients with concurrent LS and DNI (27.57 ± 14.94 days) was significantly longer than that in patients with DNI alone (10.01 ± 8.26 days; p < 0.001), and the only pathogen found in significantly different levels between the two groups was F. necrophorum (p < 0.001). Involvement of the carotid space, that of the posterior cervical space and F. necrophorum were independent risk factors for the concurrence of DNI and LS. Patients with concurrent LS and DNI had longer hospitalization periods than patients with DNI alone. Furthermore, F. necrophorum was the only pathogen found in significantly different levels in DNI patients with versus those without LS.

Case report of Lemierre's Syndrome associated with Fusobacterium nucleatum infection without internal or external jugular venous thrombophlebitis

Fusobacterium nucleatum is an anaerobe that is commensal to the human oral cavity. It is usually a component of periodontal plaque that is emerging as a pathogen and quickly attracting attention of the medical and research communities. It has been even discovered in bronchoalveolar lavage of some patients with lung cancer. Lemierre's syndrome (LS) is characterized as septic thrombophlebitis of the internal jugular vein, which usually begins with oropharyngeal infection that worsens and leads to inflammation of the wall of the jugular vein. This is the hallmark of the disease. However, in this case, there was no thrombophlebitis of the internal jugular vein. There is one other case presentation where it was diagnosed without the internal jugular vein involvement. Most sequelae involve infected thrombus of the vein, soft tissue inflammation, persistent bacteremia, and septic emboli, often leading to metastatic infections. Interestingly enough, in the age of SARS-COV-2, LS has also been mistaken for multisystem inflammatory syndrome in children (MIS-C).

We present a previously healthy 20-year-old female college student who was transferred from her local hospital to Bristol-Myers Squibb Children's Hospital (BMSCH) at Robert Wood Johnson University Hospital for suspected LS with loculated pleural effusions and necrotizing pneumonia with lung abscess secondary to Fusobacterium nucleatum, systemic and emphysematous osteomyelitis possibly secondary to septic emboli, thrombocytopenia, and palatine tonsil and thyroid abscesses.

Nonsurgical management of Fusobacterium necrophorum sternoclavicular septic arthritis: a case report

BACKGROUND

To date, the gold-standard treatment for sternoclavicular septic arthritis has been surgery due to the high failure and complication rates of medical treatment. In particular, presentation of Fusobacterium sternoclavicular septic arthritis has been rarely reported and very sparsely investigated, and only one other case report of septic arthritis caused by this pathogen exists in literature.

CASE PRESENTATION

We report a case of an otherwise healthy 38-year-old Caucasian woman who presented with sternoclavicular septic arthritis as a complication of Fusobacterium necrophorum mediastinitis. Our patient underwent successful management through nonstandard, conservative treatment of 7 weeks of intravenous piperacillin + tazobactam followed by 6 weeks of oral amoxicillin + clavulanic acid.

CONCLUSION

We highlight a case of the rare presentation of Fusobacterium necrophorum sternoclavicular septic arthritis that did not require surgical intervention for successful management. Though infection of the sternoclavicular joint is unusual, it continues to be seen in thoracic surgery, and there are increasing numbers of antibiotic-resistant organisms. This case broadens insight into the clinical course and treatment of such conditions. The success of conservative management in this case aligns with the similar nonsurgical course of the one previous report of Fusobacterium sternoclavicular septic arthritis occurrence. Thus, further discussion and thought for reevaluating the current standard practice of surgery for sternoclavicular joint infection is suggested. Our case supports assessing a patient's overall health, causative organism, and extent of infection in interventional course and taking the feasibility of conservative management into more weighted consideration.

A Review on CYP11A1, CYP17A1, and CYP19A1 Polymorphism Studies: Candidate Susceptibility Genes for Polycystic Ovary Syndrome (PCOS) and Infertility

Polycystic ovary syndrome is a multifactorial condition associated with reproductive and endocrine organs and might cause infertility and metabolic abnormalities in childbearing age. PCOS seems to be a multifactorial disorder resulting from the combination of several genetic and environmental factors. Little research has been conducted to date on the impact of polymorphisms in infertility. We aim to review the appearance of polymorphisms in females of diverse ethnicities and their effect on infertility in the population with polycystic ovary syndrome. There have been numerous reports of the importance of the steroidogenesis pathway and genetic variants in PCOS pathogenesis. The most important genes that play a role in the aetiology of PCOS are CYP11A1, CYP17A1, and CYP19A1. We evaluated the occurrence of polymorphisms in various ethnicities in the CYP11A1, CYP17A1, and CYP19A1 genes and their efficacy on increasing PCOS risk with infertility. Our findings revealed that polymorphisms in various ethnicities are associated with the risk of PCOS with infertility. Although conflicting results regarding CYP11A1, CYP17A1, and CYP19A1 polymorphisms and their influence on PCOS with infertility have been reported in a small number of papers, the authors feel this may be attributable to the sample size and ethnic composition of the examined populations. In conclusion, our study strongly suggests that the CYP11A1, CYP17A1, and CYP19A1 genes might significantly enhance the probability of developing PCOS with infertility.

Lemierre's syndrome complicated by cerebral venous sinus thrombosis: A life threatening and rare disease successfully treated with empiric antimicrobial therapy and conservative approach

Lemierre's syndrome (LS) is a "forgotten" condition characterized by septic thrombophlebitis of the jugular vein that follows an otolaryngological infection. Fusobacterium necrophorum is the aetiological agent responsible for the syndrome in adolescents and young adults whereas in older people even common bacteria are involved. Complications arise from spreading of septic emboli distally, i.e. to the brain, lungs, bones and internal organs everywhere in the body. We report a middle-aged woman who presented with headache and bilateral sixth cranial nerve palsy following a sphenoidal sinusitis and left mastoiditis. Imaging revealed thrombotic involvement of the left internal jugular vein as well as of several cerebral venous sinuses thrombosis (CVT). Currently, precise management protocols of LS with CVT complication do not exist although a combination of macrolides and second or third-generation cephalosporins, as well as anti-coagulants represent the mainstream of therapeutics. Surgical drainage is associated to remove septic foci but is burdened by severe complications and side effects. Complete recovery was achieved following pharmacological treatment in our patient. This report adds further evidence that LS complicated by CVT may be effectively treated adopting a conservative approach thus avoiding surgical drainage and severe complications.

Early Diagnosis and Antibiotic Treatment Combined with Multicomponent Hemodynamic Support for Addressing a Severe Case of Lemierre's Syndrome

A 20-year-old man was admitted to the intensive care unit for septic shock due to Lemierre’s syndrome. It is a rare syndrome that manifests as an upper respiratory infection, although systemic involvement, severe coagulopathy, and multi-organ failure can dangerously complicate the clinical picture. In this syndrome, sepsis-related neuroendocrine dysregulation and microcirculation impairment can have a rapid deleterious progression. Consequently, proper diagnosis, early source control, and appropriate antibiotics administration are mandatory to improve the prognosis. The intensive treatment is aimed at limiting organ damage through hemodynamic optimization. Remarkably, in septic shock due to Lemierre’s syndrome, hemodynamic optimization can be achieved through the synergic effect of norepinephrine, argipressin, and hydrocortisone.

Multiple Cranial Nerve Palsies in a Pediatric Case of Lemierre's Syndrome due to Streptococcus viridans

Background

Lemierre's syndrome is a rare condition of internal jugular vein thrombosis following oropharyngeal infection. While it usually results from Fusobacterium necrophorum infection, atypical cases associated with other pathogens have been reported.

Objective

To describe a unique case of pediatric Lemierre's syndrome with Streptococcus viridans infection resulting in cavernous sinus thrombosis and oculomotor, trochlear, and abducens nerve palsies. Case Report. A 14-year-old female initially presented after six days of fever, myalgias, and sore throat and was admitted for hyperbilirubinemia and acute kidney injury. She developed a fixed, dilated pupil with complete ophthalmoplegia, ptosis, and severe pain. Imaging revealed retromandibular space abscess, external and internal jugular vein thrombosis, cavernous sinus thrombosis, internal carotid artery stenosis, pulmonary embolism, and bilateral pneumonia. She was diagnosed with Lemierre's syndrome with cultures positive for Streptococcus viridans and treated with a combination of antibiotics and anticoagulation. Conclusion and Relevance. Both antibiotics and anticoagulation were effective management for this Lemierre's syndrome patient with cavernous sinus thrombosis. Early diagnosis and treatment of Lemierre's syndrome is essential. A multidisciplinary treatment team is beneficial for managing the sequelae of this condition.

A Case of Embolic Spread of Fusobacterium necrophorum From Presumed Pharyngitis

Fusobacterium necrophorum is the most common pathogen isolated in individuals diagnosed with the rare and life-threatening illness known as Lemierre's syndrome. Lemierre's syndrome commonly involves a triad of infection in the oropharyngeal region, thrombophlebitis of the internal jugular vein, and distant metastases of said infection. Our case involves an embolic spread of F. necrophorum to the lungs, which was presumed to have originated in the pharynx, in the absence of internal jugular vein thrombosis. The clinical course of the patient was further complicated by an initial diagnosis of community-acquired pneumonia, severe sepsis, and disseminated intravascular coagulation. After suitable input from the multi-disciplinary team and adequate antibiotic therapy, the patient demonstrated a positive outcome with complete recovery to her baseline.

Lemierre's syndrome causing profound thrombocytopenia and respiratory failure: a case report : Lemierre's syndrome with thrombocytopenia

Background

Lemierre’s syndrome is a rare oropharyngeal infection that can lead to metastatic septic emboli and thrombocytopenia. However, current literature does not report an effect on other cell lines, which we report for the first time in this case.

Case

A previously healthy young African American male presented with profound thrombocytopenia and leukopenia. He was tachypenic on presentation which progressed to respiratory failure requiring intubation. Blood cultures grew Fusobacterium necrophorum and imaging revealed internal jugular venous thrombosis. He was later diagnosed with Lemierre’s syndrome. The patient was treated with zosyn and fully recovered with no residual deficits in hemoglobin, white cell count, platelet level, or renal function.

Conclusion

Lemierre’s syndrome can cause severe disease in otherwise healthy patients via septicemia and widespread metastatic foci which can cause severe illness. While pulmonary complications are most common, there is little report of effects on other organ systems such as bone marrow and the kidneys. Clinicians should readily evaluate for Lemierre’s syndrome as the complications are severe and can lead to multiorgan failure.

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.

Lemierre's syndrome with cavernous sinus thrombosis caused by dental infection

Lemierre's syndrome is a rare multisystemic infection beginning in oropharynx commonly caused by oral anaerobic organisms and leading to internal jugular vein thrombosis with septic emboli. Here, we describe a 45-year-old woman with hypertension and unrecognised type 2 diabetes who presented to a community hospital with fever, double vision and septic shock. Examination showed neck pain aggravated by neck flexion, limited ocular movement of right lateral rectus, left medial rectus and left superior oblique and incomplete ptosis of the left eye. These symptoms were suggestive of bilateral cavernous sinus syndrome. CT of the brain showed bilateral proximal internal jugular vein and cavernous sinus thrombosis. CT angiography revealed septic emboli at both upper lungs. The patient had good improvement of neurological symptoms after dental extraction, intravenous antibiotic and anticoagulant.

Cavernous Sinus Thrombosis related to Orbital Cellulitis Serious Complication to Prevent: a case report and literature review

Introduction

The authors report a case which aims to underline the importance of multidisciplinary management and rapid diagnosis of orbital cellulitis, for an adequate treatment of ocular damages and related complications, to prevent serious and permanent sequelae and avoid a fatal prognosis.

Presentation of case

A 61-year-old female reported to the oral and maxillofacial surgery department after she was dragged around for two months. She presented with a right facial swelling and orbital apex syndrome including proptosis, ophthalmoplegia and ptosis.

Discussion

Complications of orbital cellulitis may be limited to the orbit, such as subperiosteal or orbital abscess, optic neuritis, blindness, or intracranial such as meningitis, sinus cavernous thrombosis, cerebral abscess and even death.

Conclusion

Maxillofacial surgeons must be aware of this complication in a multidisciplinary context to adopt adequate treatment as soon as possible.

•

Orbital cellulitis is a rare ophthalmic disease due to pansinusitis with hard maxillofacial management.

•

Cavernous sinus thrombosis is a rare but highly fatal complication of orbital cellulitis.

•

Early and appropriate treatment can improve the bad prognosis of this condition and avoid visual sequelae.

•

Maxillofacial surgeons must be aware of this complication in a multidisciplinary context to adopt adequate treatment as soon as possible.

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.

Infectious Mononucleosis Resulting in Acute Necrotizing Mediastinitis: A Case Report and Literature Review

The serological prevalence of Epstein-Barr virus (EBV) among young adults exceeds 90% worldwide. Even though EBV primary infection is usually benign, severe complications can occur in adolescents and young adults and so the disease must be promptly diagnosed. The development of an oropharyngeal abscess leading to a descending necrotizing mediastinitis (DNM) is exceptional and potentially lethal, so early diagnosis with a CT scan, appropriate antibiotics and surgery are essential. The authors present a case where DNM was associated with reactive hemophagocytic syndrome as a result of infectious mononucleosis, as well as a review of similar cases in the English literature.

LEARNING POINTS

The incidence of serious complications in Epstein-Barr virus (EBV) primary infection increases with age.Respiratory symptoms (e.g., pleuritic pain, dyspnoea) and unusually prolonged fever (>10 days) in patients with infectious mononucleosis could be 'red flags' for life-threatening complications such as empyema and descending necrotizing mediastinitis.The threshold for performing cervical and chest computed tomography in septic patients with infectious mononucleosis should be low.

Lemierre's syndrome in an intravenous drug user

A 29-year-old Dominican man with a history of intravenous heroin use and hepatitis C presented with a 5-day history of fever, dyspnoea, haemoptysis, pleuritic chest pain, abdominal pain, haematochezia and haematemesis. Initial physical examination was significant for scleral icterus, generalised abdominal tenderness to palpation, melaena and blood-tinged sputum. Blood cultures grew Fusobacterium species. CT scan of the chest revealed multiple bilateral cavitary features in lung fields. At the same time, a neck ultrasound performed demonstrated thrombophlebitis in the right internal jugular vein, confirming the diagnosis of 'Lemierre's syndrome'. Treatment was with antibiotics and supportive care for 6 weeks.

[Gynecological Lemierre's syndrome: A case report and literature review]

INTRODUCTION

Lemierre's syndrome is defined as an oropharyngeal infection due to Fusobacterium necrophorum, associated with septic thrombophlebitis of the internal jugular vein. The uncommon pelvic variant of the syndrome is a rare condition, poorly described in literature.

CASE REPORT

We report a case of gynecological Lemierre's syndrome in a 19-year-old woman after a first sexual intercourse, who presented acute respiratory failure, left internal iliac vein thrombosis with pulmonary embolism, in the setting of salpingitis and F. necrophorum bacteriemia.

CONCLUSION

Gynecological Lemierre's syndrome is a rare and unrecognized condition, which could be lethal. Early recognition of the disorder enables initiation of appropriate antibiotic therapy for 4 to 6 weeks, and discussion of anticoagulant therapy which indications are not yet well defined.

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. 

Lemierre's syndrome: A forgotten and re-emerging infection

Lemierre's syndrome, also known as post-anginal septicemia or necrobacillosis, is characterized by bacteremia, internal jugular vein thrombophlebitis, and metastatic septic emboli secondary to acute pharyngeal infections. Modern physicians have "forgotten" this disease. The most common causative agent of Lemierre's syndrome is Fusobacterium necrophorum, followed by Fusobacterium nucleatum and anaerobic bacteria such as streptococci, staphylococci, and Klebsiella pneumoniae. The causative focus mostly originated from pharyngitis or tonsillitis, accounting for over 85% of the cases of Lemierre's syndrome. Pneumonia or pleural empyema is the most common metastatic infection in Lemierre's syndrome. Antimicrobial therapy should be prescribed for 3-6 weeks. The treatment regimens include metronidazole and β-lactam antibiotics. In recent years, the antibiotic stewardship program has resulted in decreased antibiotic prescription for upper respiratory tract infections. The incidence of Lemierre's syndrome has increased over the past decade. F. necrophorum is an underestimated cause of acute pharyngitis or tonsillitis. A high index of suspicion is required for the differential diagnosis of acute tonsillopharyngitis with persistent neck pain and septic syndrome.

The Forgotten Disease: A Case of Lemierre’s Syndrome with Distal Extremity Involvement

Once coined the “Forgotten Disease,” Lemierre's syndrome is a rare condition that results from oropharyngeal infection with the gram-negative, anaerobic Fusobacterium necrophorum. The typical progression of illness involves spread to adjacent structures such as the internal jugular vein with resulting thrombophlebitis. Septic emboli to distant sites are also a common sequela. Here, we present a case of Lemierre's syndrome in a 20-year-old, otherwise healthy, male. The patient presented with fever, sore throat, and dysphagia. Imaging revealed peritonsillar multiloculated fluid collections and necrotizing pneumonia with multiple pulmonary abscesses. The patient's hospital course was complicated by the development of necrotizing fasciitis in his right lower leg, which required incision and drainage with surgical washout. In addition to systemic intravenous antibiotics and anticoagulation, he underwent multiple thoracentesis procedures. The patient was ultimately transferred to a tertiary care center due to persistent fevers and lung abscesses. This case highlights the challenges of initial diagnosis, as well as the treatment choices faced by the attending physicians.

An Unusual Case of Modified Lemierre's Syndrome Caused by Staphylococcus aureus Cellulitis

BACKGROUND Lemierre's syndrome is a potential life-threatening disease commonly occurring in young, healthy individuals. It is often preceded by an oropharyngeal infection causing bacteremia. This may rapidly progress into thrombophlebitis of the internal jugular venous system, its branches, and septic embolization and often fulminant organ failure. CASE REPORT A previously healthy 31-year-old male with recent history of facial herpes zoster infection, presented with 1-week history of increasingly painful nasal, and periorbital swelling. Imaging confirmed superior ophthalmic vein thrombosis. Staphylococcus aureus was isolated in blood cultures and had an uncomplicated hospital course with full recovery. CONCLUSIONS Early recognition of Lemierre's syndrome contributes significantly in reducing morbidity and mortality associated with it. Staphylococcus aureus skin infection is a very rare cause of Lemierre's syndrome, and its association with superior ophthalmic vein thrombosis has not yet been reported in literature.

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.

Complete Genome Sequences of Two Isolates of Fusobacterium necrophorum subsp. funduliforme, Obtained from Blood from Patients with Lemierre's Syndrome

Two isolates (F1260 and F1291) of Fusobacterium necrophorum subsp. funduliforme were recovered from blood from patients with Lemierre's syndrome. Here, we report the complete genome sequences of these two isolates. The genomes of F1260 and F1291 comprise one chromosome with lengths of 2.29 and 2.14 Mb, respectively.

Fusobacterium necrophorum sepsis after tonsillitis/pharyngitis

Fusobacterium necrophorum is a rare infection most notable for causing Lemierre's syndrome. This consists of a primary oropharyngeal infection and septic thrombophlebitis, and one or more metastatic focus. Prior to the widespread use of antibiotics, Lemierre's syndrome commonly followed a rapidly progressing course, with a high mortality. We describe a case of a previously well 18-month-old boy who presented to the emergency department with a 3-week history of progressive, right-sided, painful neck swelling and systemic sepsis. He was initially treated conservatively with intravenous antibiotics, but ultimately required surgical drainage. Lemierre's syndrome is a rare condition with increasing incidence which can have significant adverse outcomes including death. Early recognition and treatment are essential, but identifying Lemierre's disease is challenging.

Infections of the Neck

Infection of the neck is a relatively common emergency department complaint. If not diagnosed and managed promptly, it may quickly progress to a life-threatening infection. These infections can result in true airway emergencies that may require fiberoptic or surgical airways. This article covers common, as well as rare but emergent, presentations and uses an evidence-based approach to discuss diagnostic and treatment modalities.

The co-existence of Lemierre's syndrome and Bezold's abscesses due to Streptococcus constellatus: A case report

RATIONALE

The ancient infectious diseases, Lemierre's Syndrome and Bezold's Abscesses are rare.

PATIENT CONCERNS

A 70-year-old Japanese woman with a 15-year history of Parkinson's disease was referred to our hospital due to fever, occipital headache and bilateral shoulder pain that had continued for three months. She had been prescribed prednisolone due to a diagnosis of polymyalgia rheumatica.

DIAGNOSES

A blood culture revealed bacteremia of Streptococcus constellatus. In addition, computed tomography revealed Bezold's abscesses and Lemierre's syndrome.

INTERVENTIONS

We administered ceftriaxone for 31 days, followed by oral amoxicillin.

OUTCOMES

The patient recovered and the abscesses improved.

LESSONS

This case underscores the importance of blood culture tests and cross-referencing with radiological imagings in the diagnoses of these rare critical infectious diseases that mimic polymyalgia rheumatica.

A Rare Case of Lemierre-Like Syndrome: A Case Report and Literature Review

Lemierre's syndrome (LS) is a serious rare complication of oropharyngeal infections. It is characterized by thrombosis of internal jugular vein that rapidly progresses into sepsis and is typically caused by anaerobes. Most of the reported cases have been linked to Fusobacterium necrophorum; however, there are a handful of reported cases due to aerobes. It is primarily the disease of healthy young adults and can present in school-aged children. The early recognition and treatment of this complication results in resolution of the illness; nevertheless, there have been some concerns about chronic venous insufficiency as a long-term complication. We report a case of a 6-year-old boy, who presented with fever and headache with a history of sore throat. His blood culture was positive for group A Streptococcus (GAS) and was subsequently found to have internal jugular vein, sigmoid, and transverse sinus vein thrombosis.

An unusual case of cavitating pulmonary nodules: Lemierre’s syndrome with isolated involvement of the external jugular vein

A 65-year-old female presented with symptoms of tonsillitis and sepsis. Despite initial treatment with i.v. fluid and antibiotics, her condition deteriorated and she became hypoxaemic. CT pulmonary angiography showed no filling defects in the pulmonary arteries, but there were multiple cavitating lung nodules, initially thought to represent metastases. A subsequent contrast-enhanced CT of the neck and thorax demonstrated thrombosis of the left external jugular vein (EJV), leading to a revised diagnosis of Lemierre’s syndrome (i.e. septic embolization from jugular thrombophlebitis). Noteworthy aspects of the case include the initial misdiagnosis of the cavitating lung nodules by the reporting radiologist and the isolated involvement of the EJV—Lemierre’s syndrome usually involves the internal jugular vein. The case highlights the importance of septic emboli in the differential diagnosis of cavitating lung nodules, and of assessment of the EJV as well as internal jugular vein in the context of oropharyngeal infection.

Lemierre's syndrome: forgotten, but not absent

Lemierre's syndrome is rare, with no known reported cases in the Caribbean thus far. We highlight a case of a young woman who presented with diabetic ketoacidosis precipitated by oral pharyngeal sepsis, whose condition rapidly deteriorated within 24 hours requiring ventilation and administration of antibiotics. Her sepsis was accompanied by internal jugular vein thrombosis in keeping with a diagnosis of Lemierre's syndrome, which was treated aggressively with antibiotics, intensive care and mechanical ventilatory support in the intensive care unit. She made a full recovery. Though this is the first reported case in the Caribbean of this ‘forgotten disease’, it must not be forgotten because prognosis and outcome are markedly improved with prompt and aggressive treatment.

Lemierre's syndrome: Case report and brief literature review

Lemierre’s syndrome has been shown to be increasing in incidence in the past 20 years with one popular suggesting that said rise occurred from less aggressive antibacterial coverage. We report a case of Lemierre’s syndrome and also reviewed the 15 most recent case reports. A previously healthy 25 year old male who initially developed sore throat and flu-like symptoms, was prescribed antibacterials as an outpatient but was hospitalized for worsening symptoms. He was later diagnosed with Lemierre’s syndrome and improved clinically with IV antimicrobials alone. From our concise literature review, we determined that a decrease in antibiotic prescriptions may not fully explain why the incidence of Lemierre’s has been increasing. Thus, future research should be focused in evaluating possible worsening susceptibilities to antibiotics and improvements on detection. We also advise physicians to be aware of the signs and symptoms of this rare but potentially fatal condition as well as the available detection methods and treatment

Fusobacterial liver abscess: a case report and review of the literature

Background

Fusobacteriae are facultative anaerobic gram-negative bacilli which cause a range of invasive infections, amongst which pyogenic liver abscesses are rare. We describe a case of Fusobacterium nucleatum liver abscess and review the relevant literature.

Case presentation

A 51-year-old lady presented with a 4-day history of abdominal pain, diarrhoea, fever, rigors, and lethargy. Imaging revealed an abscess which was drained. Cultures of the blood and abscess aspirate grew Fusobacterium nucleatum and Prevotella pleuritidis respectively. She achieved full recovery following treatment.

A MEDLINE search was undertaken using free-text and Medical Subject Headings (MeSH), keywords “Fusobacterium” and “Liver abscess”. Non-English language reports and cases without confirmed growth of Fusobacterium species were excluded. Additional cases were identified by surveying the references of each report and by using the same keywords in a web-based search.

Forty-eight cases were identified, 41 in men. The median age was 42.5, with an interquartile range of 33. F. nucleatum and F. necrophorum were in involved in 22 cases each, and 4 cases were not further speciated. Among cases of F. nucleatum liver abscess, nine were attributed to periodontal disease, four to lower gastrointestinal tract disease, one to Lemierre’s Syndrome, and eight were considered cryptogenic. All patients treated made a full recovery. Antimicrobial treatment duration ranged from 2 weeks to 6 months with a median of 6 weeks.

Conclusion

Fusobacterium nucleatum is an uncommon cause of liver abscess generally associated with good clinical outcomes with contemporary medical and surgical care.

Methicillin-resistant Staphylococcus aureus as a Cause of Lemierre's Syndrome

Lemierre's syndrome (LS) or jugular vein suppurative thrombophlebitis is well described in literature. The organisms most often responsible are Fusobacterium necrophorum or anaerobic flora. We present a case of LS with an atypical microbiologic cause, methicillin-resistant Staphylococcus aureus. We also present retrospective review of all LS cases from our institution and identified 2 additional children with LS caused by methicillin-resistant S. aureus.

Lemierre's Syndrome - A rare cause of disseminated sepsis requiring multi-organ support

Lemierre's syndrome is a rare complication of acute pharyngitis characterised by septicaemia with infective thrombophlebitis of the internal jugular vein, most commonly due to Fusobacterium necrophorum. It characteristically affects healthy young adults causing persistent pyrexia and systemic sepsis presenting several days after an initial pharyngitis. Septic emboli seed via the bloodstream to distant sites including the lung, joints, skin, liver, spleen and brain. Prolonged antimicrobial therapy is required and admission to intensive care common. This once rare condition is increasing in incidence but awareness amongst clinicians is low. We present a classic case in a young man who developed multi-organ failure requiring intensive care support and describe the epidemiology, pathophysiology, microbiology, clinical features and management of the disease.