Jugular Vein Thrombosis and Anticoagulation Therapy in Lemierre's Syndrome-A Post Hoc Observational and Population-Based Study of 82 Patients

A rare case of MRSA associated Lemierre's syndrome

Lemierre's syndrome, or postanginal sepsis, is an uncommon but potentially fatal infection of the internal jugular vein. The combination of bacteremia, internal jugular vein thrombophlebitis, and metastatic septic emboli secondary to acute pharyngeal infections is characteristic of Lemierre's syndrome. Isolated pathogens are typically oral anaerobic bacteria, most commonly Fusobacterium necrophorum. While the incidence of Lemierre's syndrome has declined over the years, the proportion of cases caused by uncommonly implicated bacteria have been increasingly cited in the literature (1). In this case report, we introduce a novel presentation of Lemierre's syndrome in a patient who presented to the emergency department with neck swelling and shortness of breath and was found to have infectious myositis and bacteremia with methicillin-resistant Staphylococcus aureus. Clinicians should be vigilant of underlying thrombus in patients with neck swelling and infectious myositis as our patient's internal jugular vein thrombus was missed on initial computed tomography read.

A 36-Year-Old Male With Left-Sided Neck Pain and Progressive Dyspnea

CASE PRESENTATION

A 36-year-old male with no significant medical history presented to the ED with progressive left-sided neck and facial pain for the last 7 days. The patient also reported subjective fevers, chills, difficulty opening his mouth, and anorexia for the last 1 week. He denied cough, chest pain or tightness, shortness of breath, skin rashes, dysphagia, or odynophagia. He reported use of two to three 59.15 mL beers daily for the last 20 years. There was no recent travel or sick contact exposure. He did not report any TB exposure, IV drug use, or recent sexual encounters.

Proteomic Characterization of Plasma in Lemierre's Syndrome

BACKGROUND

 The underlying mechanisms of thrombosis in Lemierre's syndrome and other septic thrombophlebitis are incompletely understood. Therefore, in this case control study we aimed to generate hypotheses on its pathogenesis by studying the plasma proteome in patients with these conditions.

METHODS

 All patients with Lemierre's syndrome in the Skåne Region, Sweden, were enrolled prospectively during 2017 to 2021 as cases. Age-matched patients with other severe infections were enrolled as controls. Patient plasma samples were analyzed using label-free data-independent acquisition liquid chromatography tandem mass spectrometry. Differentially expressed proteins in Lemierre's syndrome versus other severe infections were highlighted. Functions of differentially expressed proteins were defined based on a literature search focused on previous associations with thrombosis.

RESULTS

 Eight patients with Lemierre's syndrome and 15 with other severe infections were compared. Here, 20/449 identified proteins were differentially expressed between the groups. Of these, 14/20 had functions previously associated with thrombosis. Twelve of 14 had a suggested prothrombotic effect in Lemierre's syndrome, whereas 2/14 had a suggested antithrombotic effect.

CONCLUSION

 Proteins involved in several thrombogenic pathways were differentially expressed in Lemierre's syndrome compared to other severe infections. Among identified proteins, several were associated with endothelial damage, platelet activation, and degranulation, and warrant further targeted studies.

Lemierre syndrome with pulmonary empyema caused by Prevotella intermedia

Lemierre syndrome is a rare disease that is most often caused by Fusobacterium necrophorum We present a case caused by Prevotella intermedia in a young, healthy man, complicated by multiple cavitary lung lesions, loculated pleural effusions requiring chest tube placement and trapezius abscess. Our case highlights (a) P. intermedia as a rare cause of Lemierre syndrome and (b) clinical response to appropriate antimicrobial therapy may be protracted.

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.

Gastrointestinal Variant of Lemierre Syndrome due to Fusobacterium nucleatum: A Case Report

Introduction

Pyogenic liver abscess is a noteworthy health concern in North America, characterized by a mortality rate ranging from 2 to 12%. This condition is often polymicrobial, with Streptococcus species and Escherichia coli as the predominant causal pathogens in Western countries. Fusobacterium species, typically commensals of gastrointestinal, genital, and oral flora, have been implicated in the rare formation of tonsillar abscesses and Lemierre syndrome, including its gastrointestinal variant known as pylephlebitis.

Case Presentation

We present the case of an immunocompetent male with a 2-week history of abdominal distention and pain. Abdominal magnetic resonance imaging revealed multiseptated cystic hepatic masses and portal vein thrombosis. A subsequent liver biopsy confirmed Fusobacterium nucleatum etiology. The patient was initiated on intravenous cefepime and oral metronidazole antibiotics. Unfortunately, the patient succumbed to cardiac arrest before a final diagnosis could be established.

Conclusion

Fusobacterium species-associated liver abscess, coupled with the rare gastrointestinal variant of Lemierre syndrome (pylephlebitis), poses a significant mortality risk. This case underscores the rarity and clinical challenges associated with these conditions. Increased awareness among clinicians is crucial for early diagnosis and prompt intervention, potentially improving outcomes in such cases.

Common laboratory tests and their correlation with the clinical presentation and prognosis of Lemierre syndrome

INTRODUCTION

Lemierre syndrome is a thromboembolic complication following an acute bacterial infection of the head/neck area, often due to anaerobes. Data on the prognostic role of laboratory parameters is lacking.

METHODS

We analyzed individual-patient level data from a multinational cohort of patients with Lemierre-syndrome. Patients had an infection in the head/neck area, and contiguous vein thrombosis or septic embolism, irrespective of the causal pathogen. We studied the patterns of white blood cell count, platelet count, and C-reactive protein concentration investigating their association with baseline characteristics and in-hospital clinical outcomes (septic embolism, major bleeding, all-cause death).

RESULTS

A total of 447 (63%) patients had complete data for analysis. White blood cells were elevated across all subgroups (median 17 × 103/μL; Q1-Q3:12-21). Median platelet count was 61 × 103/μL (Q1-Q3:30-108) with decreasing levels with increasing age. Males, patients with renal failure or cardiopulmonary impairment, and those with typical Lemierre syndrome (tonsillitis, septic thromboembolism, positivity for Fusobacterium spp.) had the lowest platelet count. Median C-reactive protein was 122 (Q1-Q3:27-248) mg/L with higher values in patients who also had more severe thrombocytopenia. The overall risk of complications was similar across subgroups of patients stratified according to white blood cell and C-reactive protein levels. Patients in the lowest third of platelet count (<42 × 103/μL) had the highest rate of complications (26%), as opposed to those in the highest third (11%), notably septic embolic events.

CONCLUSIONS

Common laboratory tests correlate with the clinical presentation of Lemierre syndrome. However, extreme values did not appear to be prognostically relevant for in-hospital complications and potentially able to improve clinical management.

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 Syndrome Complicated by Emphysematous Osteomyelitis

Lemierre syndrome is characterized by severe pharyngitis, internal jugular vein thrombosis, and septic emboli. We present a case of emphysematous osteomyelitis secondary to Lemierre syndrome in a 27-year-old previously healthy man. Despite the high mortality associated with these conditions, full symptom resolution can be achieved with early diagnosis and aggressive management.

Complex Lemierre syndrome with multisystemic abscesses

We present here the challenging case of severe Lemierre syndrome in a healthy woman in her late twenties, whose clinical presentation was characterised by lung abscesses and disseminated systemic abscesses in the brain, the abdomen and the soft-tissues, as a likely consequence of a patent foramen ovale. Blood cultures were positive for Fusobacterium necrophorum and a right lingual vein thrombosis was detected at a late stage when the patient developed a septic shock. Initial antimicrobial therapy with metronidazole and ceftriaxone was modified to meropenem due to progressive worsening. The patient underwent laparoscopy and neurosurgical drainage of a cerebral abscess. She spent many days in the intensive care unit and recovered fully after 6 weeks on meropenem therapy. Although considered rare, the incidence of Lemierre syndrome, a potentially life-threatening condition, is increasing. The clinician should promptly recognise and treat it while being aware of its potential atypical presentations.

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.

Elderly onset atypical Lemierre's syndrome concurrent with a rheumatoid vasculitis sacral ulcer infection: a case report

BACKGROUND

Typical Lemierre's syndrome is usually secondary to an oropharyngeal infection. Recently, several cases following a primary infection site other than the oropharynx have been reported as atypical Lemierre's syndrome; although, these primary lesions are limited to the head and neck. This is the first case potentially sequential to infectious foci outside the head and neck.

CASE PRESENTATION

We describe an atypical Lemierre's syndrome in a 72-year-old woman with rheumatoid arthritis, which occurred during the treatment of Streptococcus anginosus bacteremia acquired from a sacral ulcer infection related to rheumatoid vasculitis. At first, the symptoms resolved after the initial administration of vancomycin for the bacteremia caused by methicillin-resistant Staphylococcus aureus and Streptococcus anginosus that entered via a sacral ulcer. On the 8th day, the patient developed a fever of 40 °C and unexpectedly required 10 L of oxygen due to rapid deterioration of oxygenation temporarily. Immediately contrast-enhanced computed tomography was performed to investigate systemic thrombosis including pulmonary embolism. Afterward, the newly formed thrombi at the right external jugular vein, bilateral internal jugular veins, and the right small saphenous vein were detected, and apixaban was started. On the 9th day, the patient again had an intermittent fever of 39.7 °C, and continuous Streptococcus anginosus bacteremia was revealed; subsequently, clindamycin was administered. On the 10th day, she developed a left hemothorax; consequently, apixaban was discontinued, and a thoracic drain was inserted. She repeatedly had an intermittent fever of 40.3 °C, and contrast-enhanced computed tomography detected an abscess formation at the left parotid gland, pterygoid muscle group, and masseter muscle. After Lemierre's syndrome was diagnosed in combination with the abovementioned jugular vein thrombus, clindamycin was replaced with meropenem, and vancomycin was increased. Swelling of the lower part of the left ear became prominent with delay and peaked at approximately the 16th day. The subsequent treatment course was favorable, and she was discharged on the 41st day.

CONCLUSION

Clinicians should consider Lemierre's syndrome as the differential diagnosis of internal jugular vein thrombosis occurring during sepsis, even though an antibiotic is administered or a primary infection site is anything besides the oropharynx.

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.

Lemierre's Syndrome in the External Jugular Vein Precipitated by COVID-19 Infection

Lemierre's syndrome is a condition when an oropharyngeal infection, typically from Fusobacterium necrophorum, causes thrombophlebitis of the internal jugular vein. There have been few case reports of Lemierre's syndrome affecting the external jugular vein, but to our knowledge, this is the first case report where COVID-19 infection is the prime suspect for causing this syndrome. SARS-CoV-2 infection, known to cause hypercoagulability and immunosuppression, increases the risk of deep venous thrombosis and secondary infections. We report a case of a young male with no known risk factors who developed Lemierre's syndrome as a complication of COVID infection.

Myometritis with pelvic septic vein thrombophlebitis secondary to Fusobacterium necrophorum sepsis

A young woman in her 20s presented with fever, abdominal pain and malodourous vaginal discharge. She was found to be in septic shock, in the setting of a recent medical abortion with subsequent intrauterine device placement. Her blood cultures grew Fusobacterium necrophorum Despite appropriate antibiotic therapy, the fever failed to defervesce. Subsequent evaluation revealed septic thrombophlebitis of the right gonadal vein and branches of the right iliac vein. She improved with a prolonged course of targeted antimicrobial therapy.

Associations Between Findings of Fusobacterium necrophorum or β-Hemolytic Streptococci and Complications in Pharyngotonsillitis-A Registry-Based Study in Southern Sweden

BACKGROUND

Most pharyngotonsillitis guidelines focus on the identification of group A streptococci (GAS), guided by clinical scores determining whom to test with a rapid antigen detection test. Nevertheless, many patients testing negative with this test are evaluated for group C/G streptococci (GCS/GGS) and Fusobacterium necrophorum, yet their importance remains debated. Our primary aim was to evaluate associations between complications and findings of F. necrophorum, GAS, or GCS/GGS in pharyngotonsillitis.

METHODS

This was a retrospective, registry-based study of pharyngotonsillitis cases tested for F. necrophorum (polymerase chain reaction) and β-hemolytic streptococci (culture) in the Skåne Region, Sweden, in 2013-2020. Patients with prior complications or antibiotics (within 30 days) were excluded. Data were retrieved from registries and electronic charts. Logistic regression analyses were performed with a dichotomous composite outcome of complications as primary outcome, based on International Classification of Diseases, Tenth Revision, codes. Cases with negative results (polymerase chain reaction and culture) were set as reference category. Complications within 30 days were defined as peritonsillar or pharyngeal abscess, otitis, sinusitis, sepsis or septic complications, recurrence of pharyngotonsillitis (after 15-30 days) or hospitalization.

RESULTS

Of 3700 registered cases, 28% had F. necrophorum, 13% had GCS/GGS, 10% had GAS, and 54% had negative results. The 30-day complication rates were high (20%). F. necrophorum (odds ratio, 1.8; 95% confidence interval, 1.5-2.1) and GAS (1.9; 1.5-2.5) were positively associated with complications, whereas GCS/GGS were negatively associated (0.7; 0.4-0.98).

CONCLUSIONS

Our results indicate that F. necrophorum is a relevant pathogen in pharyngotonsillitis, whereas the relevance of testing for GCS/GGS is questioned. However, which patient to test and treat for F. necrophorum remains to be defined.

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.

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.

Short blood culture time-to-positivity in Fusobacterium necrophorum bacteremia is associated with Lemierre's syndrome

The usefulness of blood culture time-to-positivity (TTP) in the diagnosis of endovascular infections has previously been shown. Here, we investigated TTP in 41 patients with F. necrophorum bacteraemia and found an association between short TTP and Lemierre's syndrome (p = 0.026).

Lemierre's syndrome by Bacillus circulans, Fusobacterium nucleatum and Staphylococcus aureus with involvement of the internal and external jugular vein

Introduction

Lemierre's syndrome refers to the septic thrombophlebitis of the internal jugular vein, secondary to a pharyngeal infection. Although it mainly affects the internal jugular vein, isolated cases have been described of involvement of the external jugular vein. The main etiological agent is Fusobacterium necrophorum.

Case report

A 27-year-old male, previously healthy, presented with a 7-day history of sore throat and fever. He was diagnosed with Lemierre's syndrome, coinfection by Bacillus circulans, F. nucleatum and Staphylococcus aureus with an atypical presentation due to the involvement of the external jugular vein and the internal jugular vein.

Conclusions

As far as we are aware, we present the first case of Lemierre's syndrome with these characteristics.

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.

Management of Lemierre syndrome

Lemierre syndrome is a rare form of septic thrombophlebitis of the head and neck veins, most typically the internal jugular vein, which affects otherwise healthy adolescents and young adults after an oropharyngitis or other local infection and is characterized by multiple septic embolization. Despite treatment, Lemierre syndrome displays a high rate of in-hospital complications that include thrombus progression and new peripheral septic embolization, and it can be fatal or cause disabling sequelae. The mainstay of treatment is antibiotic therapy; anticoagulation is often used, but its role is controversial. Surgical treatment is often necessary in case of peripheral septic lesions. In the absence of prospective studies, what little guidance exists on its management is based on case series or on analogy with similar conditions such as other forms of septic thrombophlebitis or non-septic venous thrombosis. Over the last few years, new observational evidence has improved our knowledge of the clinical epidemiology of this condition and highlighted a number of promising management strategies. We provide an overview of the treatment patterns observed in the contemporary era, summarise the arguments proposed so far against or in favour of alternative treatments as well as possible decision rules on the use of anticoagulation, and outline the priorities of ongoing and future observational and interventional research.