Lemierre's syndrome

Lemierre syndrome in a child with recent pharyngitis

A 14-year-old boy presented with fever and progressive respiratory distress, one week after an episode of pharyngitis. Although there was a concern about pulmonary embolism secondary to a lower extremity fracture, his presentation was most consistent with Lemierre syndrome. This syndrome is an uncommon but potentially lethal complication of otolaryngological infections. Early recognition and aggressive antibiotic therapy are critical elements in reducing mortality. Emergency physicians should be aware of this syndrome because its incidence appears to be increasing.

Lemierre's syndrome: A systematic review

OBJECTIVES/HYPOTHESIS

Lemierre's syndrome is characterized by a history of recent oropharyngeal infection, clinical or radiological evidence of internal jugular vein thrombosis, and isolation of anaerobic pathogens, mainly Fusobacterium necrophorum. It was once called the forgotten disease because of its rarity, but it may not be that uncommon after all. This review aims to provide physicians with an update on the etiology, management, and prognosis of Lemierre's syndrome.

METHODS

Systematic review using the terms: Lemierre's syndrome, postanginal septicemia, fusobacterium, internal jugular vein thrombosis.

INCLUSION CRITERIA

English literature; reviews, case reports, and case series.

EXCLUSION CRITERIA

variants or atypical Lemierre's syndrome cases, negative fusobacteria cultures, and papers without radiological evidence of thrombophlebitis.

RESULTS

Eighty-four studies fulfilled our inclusion criteria. The male to female ratio was 1:1, 2, and the ages ranged from 2 months to 78 years (median, 22 years). Main sources of infection were tonsil, pharynx, and chest. Most common first clinical presentation was a sore throat, followed by a neck mass and neck pain. The most common offending micro-organism was F. necrophorum. Treatment modalities used were antimicrobial, anticoagulant, and surgical treatment. Morbidity was significant with prolonged hospitalization in the majority of patients. The overall mortality rate was 5%.

CONCLUSIONS

Lemierre's syndrome may not be as rare as previously thought. This apparent increase in the incidence may be due to antibiotic resistance or changes in antibiotic prescription patterns. Successful management rests on the awareness of the condition, a high index of suspicion, and a multidisciplinary team approach.

An autopsy case of internal jugular vein thrombophlebitis involving sepsis following blunt neck injury

We report an unusual case of delayed death due to sepsis following closed blunt injury to the neck. The victim was a 71-year-old male with a clinical history of hypertension, diabetes and gout. He was found dead about three weeks after being assaulted. He had not consulted a hospital after the assault. Forensic autopsy demonstrated a large liquefied subcutaneous hematoma on the right side of the neck, peri- and thrombophlebitis of the right internal jugular vein. Otherwise, there was no evidence of trauma. Histological examination showed dermal vesicles in the skin covering the hematoma, accompanied by marked inflammatory cell infiltration phagocytosing gram-positive streptococci, subcutaneous edema, panphlebitis with partially organized thrombi and bacterial colonies, pulmonary edema and multiple pulmonary microthrombi involving bacterial aggregates. Postmortem serum C-reactive protein and neopterin levels were markedly elevated. These findings suggest sepsis as the cause of death, induced by infected internal jugular vein thrombophlebitis following blunt neck injury involving impaired skin barrier.

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

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

Sigmoid Sinus Thrombosis Secondary to Lemierre's Syndrome

Lemierre's syndrome, a rare and almost forgotten cause of internal jugular vein thrombosis, is usually caused by an anaerobic head and neck infection. Left untreated, it can result in the release of septic emboli. We describe the case of a 42-year-old man who presented with fever and a tender, swollen neck mass. Computed tomography revealed an edematous parapharyngeal area and a compressed internal jugular vein. Despite antibiotic treatment, the patient's condition worsened, and a parapharyngeal fluid collection was drained 4 days later. Six weeks later, the patient returned to the outpatient department complaining of headaches, and he was found to have a tender, firm neck. He was readmitted, and magnetic resonance venography revealed a right internal jugular vein thrombosis that extended intracranially to the sigmoid sinus. He was anticoagulated for 6 months, and he remained well during outpatient follow-up. We examine the controversial roles that anticoagulation and thrombolysis play in Lemierre's syndrome and sigmoid sinus thrombosis, and we review the diagnostic options.

Lemierre's syndrome: more than a historical curiosa

Lemierre's syndrome is a severe illness caused by the anaerobic bacterium, Fusobacterium necrophorum which typically occurs in healthy teenagers and young adults. The infection originates in the throat and spreads via a septic thrombophlebitis of the tonsillar vein and internal jugular vein. The ensuing bacteraemia is complicated by septic emboli to a range of sites such as lung, joints, and bones. Although rare, there is evidence of a resurgence in the condition in recent years, possibly associated with reduced use of antibiotic therapy for sore throats. The typical clinical picture is characteristic but many clinicians are unaware of the condition and diagnosis is often delayed with potentially fatal consequences.

Critical care nurses be aware: Lemierre's syndrome is on the rise

Lemierre's syndrome (LS) typically occurs in previously healthy young adolescents and young adults who become acutely ill following an attack of pharyngotonsillitis. Also known as post anginal sepsis, those afflicted develop pyrexia, rigours and multiple metastatic abscesses that lead to septic thrombophlebitis of the internal jugular vein. In the pre-antibiotic era this particularly virulent syndrome had a mortality rate in excess of 90%, but since the introduction of antibiotics and the widespread treatment of throat infections, it has became almost unknown. However, due to a number of factors, including a reduction in the use of antibiotics for the treatment of sore throats, misdiagnosis and/or improvements in microbiology diagnostic techniques, several reports have indicated a resurgence of the condition. This has major ramifications for critical care nurses as LS is still associated with significant morbidity and mortality. This paper discusses the aetiology, pathophysiology, bacteriology, diagnosis and management aspects of this syndrome. A case study of a young woman is presented to illustrate the complexity of the condition, and highlight how early diagnosis and prompt initiation of appropriate intravenous antibiotic therapy ensured a favourable clinical outcome.

Deep Fascial Space Infection of the Neck: A Continuing Challenge

We present our clinical experience with two complex cases of deep fascial space infections of the neck. The first was a case of cervical necrotizing fasciitis involving the submental space. The second was an infection beginning at the soft palate and extending to the anterior mediastinum. Both infections emanated from an oral source in patients with diabetes mellitus, and both patients required multiple surgical debridements and endotracheal intubation for airway protection. Despite the declining incidence of deep space neck infections, our cases illustrate the challenging diagnostic and treatment dilemmas for the clinician managing patients with diabetes.

Unusual presentation of Lemierre's syndrome due to Fusobacterium nucleatum

We report a case of Lemierre's syndrome due to Fusobacterium nucleatum in a previously healthy 19-year-old male. This is the first case report of Lemierre's syndrome due to thrombophlebitis of the external jugular vein. The patient had a rapid clinical response to anticoagulation and antibiotics, as supported by anecdotal evidence.

Lemierre's syndrome: post-anginal septicemia

Lemierre's syndrome is an obscure entity with very significant related morbidity. We describe a typical case and a never before reported complication. Increased awareness of this condition is necessary, since it is given little consideration even when patients present with the very characteristic clinical picture. US will depict internal jugular vein (IJV) thrombosis in most cases and should be the modality of choice for the initial evaluation of suspected thrombosis of the IJVs. Associated demonstration of cavitary pulmonary nodules establishes the diagnosis of Lemierre's syndrome. Early recognition and institution of adequate antimicrobial therapy are key points in the successful management of this syndrome.

The evolution of Lemierre syndrome: report of 2 cases and review of the literature

Lemierre syndrome (postanginal septicemia) is caused by an acute oropharyngeal infection with secondary septic thrombophlebitis of the internal jugular vein and frequent metastatic infections. A high degree of clinical suspicion is necessary for diagnosis. Fusobacterium necrophorum is the usual etiologic agent. The disease progresses in several steps. The first stage is the primary infection, which is usually a pharyngitis (87.1% of cases). This is followed by local invasion of the lateral pharyngeal space and IJV septic thrombophlebitis (documented in 71.5% of cases), and finally, the occurrence of metastatic complications (present in 90% of cases at the time of diagnosis). A sore throat is the most common symptom during the primary infection (82.5% of cases). During invasion of the lateral pharyngeal space and IJV septic thrombophlebitis, a swollen and/or tender neck is the most common finding (52.2% of patients) and should be considered a red flag in patients with current or recent pharyngitis. The most common site of metastatic infection is the lungs (79.8% of cases). In contrast to the preantibiotic era, cavitating pneumonia and septic arthritis are now uncommon. Most patients (82.5%) had fever at some stage during the course of the disease. Gastrointestinal complaints such as abdominal pain, nausea, and vomiting were common (49.5% of cases). An elevated white blood cell count occurred in 75.2% of cases. Hyperbilirubinemia with slight elevation of liver enzyme levels occurred in one-third of patients, but frank jaundice was uncommon, in contrast to its high frequency reported in the preantibiotic era. We conclude that, most likely as a consequence of widespread antibiotic use for pharyngeal infections, the typical course of the disease has changed since Lemierre's original description. The typical triad in our series was: pharyngitis, a tender/swollen neck, and noncavitating pulmonary infiltrates. The previous classical description of severe sepsis with cavitating pneumonia and septic arthritis was not commonly seen in our review. Mortality was low in our series (6.4%), but significant morbidity occurred, which was likely preventable by early diagnosis and treatment. The pathophysiology, natural history, diagnostic methods for internal jugular vein thrombosis, and management are discussed.

Bilateral Lemierre's Syndrome: A Case Report and Literature Review

Lemierre's syndrome is characterized by thrombosis of the internal jugular vein that develops following an oropharyngeal infection. Sepsis and septic metastases frequently ensue and affect the lungs, the musculoskeletal system, and occasionally the liver. Most cases are caused by infection with Fusobacterium necrophorum. This infection responds to antibiotic therapy with beta-lactamase-resistant compounds that exert good anaerobic coverage. Anticoagulation and surgical intervention can be helpful in advanced cases. Fewer than 160 cases of classic Lemierre's syndrome have been described; approximately one-third of these reported cases have occurred since 1988. We describe a new case of Lemierre's syndrome that occurred in an otherwise healthy 27-year-old man. Thrombosis of both internal jugular veins extended through the subclavian system and into both upper extremities. The patient was treated with intravenous antibiotics and heparin during 14 days of hospitalization. He was discharged on oral clindamycin and warfarin sodium, and after 6 months he was able to return to full activity. To our knowledge, this is the first reported case of Lemierre's syndrome in which internal jugular vein thrombosis occurred bilaterally. By reporting this previously undescribed manifestation of Lemierre's syndrome, we hope to increase practitioner awareness of this disease entity.

Early antibiotic treatment may prevent complete development of Lemierre's syndrome: experience from 2 cases

Lemierre's syndrome is a rare fulminant condition caused by an acute oropharyngeal infection, with secondary septic thrombophlebitis of the internal jugular vein complicated by multiple metastatic infections. Herein we report 2 patients with internal jugular vein thrombosis secondary to oropharyngeal infection, whose clinical course was indolent, and who were asymptomatic shortly after antibiotic therapy was begun. Careful examination of the neck in patients presenting with sore throat could help identify the typical 'cord sign'. In such cases, intravenous antibiotic treatment should be started as soon as possible to prevent development of metastatic infections and septicaemia characterizing Lemierre's syndrome.

Spiral CT findings in septic pulmonary emboli

OBJECTIVES

The aim of the study was to determine the characteristics of septic pulmonary emboli and their prevalence on spiral computed tomographic (CT) scans.

METHODS AND MATERIALS

We evaluated 65 lesions on spiral CT scans in ten patients with septic pulmonary emboli. Spiral CT scans (10-mm collimation) were obtained at 10-mm intervals from the lung apex to the diaphragm and were compared with posteroanterior chest radiographs obtained within 24 h after CT scanning.

RESULTS

Only 21 (32%) of the 65 lesions detected on CT scans were also detected on chest radiographs. Peripheral nodules (39 lesions (60%)) were seen in all ten patients, wedge-shaped peripheral lesions (15 lesions (23%)) in nine patients, and infiltrates (11 lesions (17%)) in four patients. Subpleural lesions (45 lesions (69%)) and feeding vessels (35 (54%)) were found in all patients, and cavitary lesions (seven lesions (11%)) were seen in four patients. Subpleural peripheral nodules and wedge-shaped peripheral lesions were seen in nine patients. Thirty-two lesions (49%) ranged in diameter from 10 to 19 mm, and 59 lesions (91%) were less than 30 mm.

CONCLUSIONS

Spiral CT is useful in detecting septic pulmonary emboli. On spiral CT subpleural peripheral nodules and wedge-shaped peripheral lesions less than 30 mm in diameter are often found in patients with septic pulmonary emboli.

Human necrobacillosis, with emphasis on Lemierre's syndrome

Lemierre's syndrome is the classical presentation of human necrobacillosis. It is characterized by a primary infection in the head in a young, previously healthy person who subsequently develops persistent high fever and disseminated metastatic abscesses, frequently including a septic thrombophlebitis of the internal jugular vein. The main pathogen is Fusobacterium necrophorum, an obligate anaerobic, pleomorphic, gram-negative rod. Clinical microbiologists have a key role in alerting clinicians and advising proper antibiotic treatment when the characteristic microscopic morphology of the pleomorphic F. necrophorum is seen in Gram stains from positive anaerobic cultures of blood and pus. Early diagnosis and prolonged appropriate antibiotic treatment with good anaerobic coverage are crucial to reduce morbidity and mortality. F. necrophorum also causes human necrobacillosis with foci caudal to the head, mainly in elderly patients with high mortality related to age and predisposing diseases, such as cancers of the primary focus.

Lemierre's Syndrome

Lemierre's syndrome is characterized by an oropharyngeal infection followed by internal jugular vein septic thrombophlebitis and metastatic emboli, most often to the lungs and joints. The syndrome is most commonly associated with the anaerobic gram-negative rod Fusobacterium necrophorum. Diagnosis is established with evidence of metastatic infection and internal jugular vein thrombophlebitis. CT is considered the diagnostic procedure of choice. Treatment should include an extended course of a beta-lactamase-resistant antibiotic and surgical drainage of any purulent fluid collection. Anticoagulation remains controversial, and ligation of the internal jugular vein is reserved for patients with persistent sepsis and recurrent emboli. With appropriate therapy, mortality is 4% to 12%; but mortality is increased when therapy is delayed.

Lemierre syndrome: forgotten but not extinct--report of four cases

Four cases of Lemierre syndrome are reported in which metastatic abscesses resulted from septic thrombosis of the internal jugular vein secondary to bacterial pharyngitis. While chest radiographic findings were nonspecific, results of computed tomography (CT) of the thorax in each case were highly suggestive of septic pulmonary emboli. Internal jugular venous thrombosis was demonstrated at ultrasonography and contrast material-enhanced CT.