Lemierre syndrome: a case report

Lung abscess as a complication of Lemierre Syndrome in adolescents: a single center case reports and review of the literature

BACKGROUND

Fusobacterium necrophorum is an anaerobic, gram-negative, non-motile, filamentous, non-spore forming bacillus found in the oral cavity, gastrointestinal tract, and female genital tract, responsible of a rare disease named Lemierre Syndrome, characterized by septic thrombophlebitis of the internal jugular vein, which mainly affects previously healthy adolescents and young adults; some risk factors are reported, as smoking or primary viral or bacterial infection leading to the disruption of mucosa. The syndrome originates commonly from an upper respiratory infection such as pharyngotonsillitis, acute otitis media, cervical lymphadenitis, sinusitis, or odontogenic abscess, and may result in multiorgan metastasis, more frequently leading to pulmonary complications, especially lung abscesses.

CASE PRESENTATION

We describe two cases of adolescents with atypical Lemierre Syndrome evaluated in a tertiary care center, one with a confirmed infection by Fusobacterium necrophorum and one with a presumptive diagnosis based on clinical features, who developed lung abscesses needing a prolonged antibiotic course and hospitalization. Of interest, both were user of electronic cigarette, configuring a possible new risk factor. The proper diagnosis of Lemierre Syndrome is often difficult to establish, so a high degree of suspicion is needed, especially in the case of lung abscesses in otherwise healthy adolescents.

CONCLUSION

The current study will contribute to providing insight into Lemierre Syndrome clinical presentation and management in adolescents, promoting awareness for a rare but potentially fatal disease. Moreover, it suggests a possible relationship between Lemierre syndrome and the use of electronic cigarette, that should be investigated by future studies.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Incomplete Lemierre syndrome

An invasive Fusobacterium infection may originate from an apparent routine pharyngitis and lead to significant distant septic complications. Even without internal jugular thrombosis, the same mechanism of disease exists, and therefore, the same morbidity, prognosis, and treatments are applicable, hence the suitable term incomplete Lemierre syndrome. We present a case of invasive Fusobacterium infection that meets all criteria for Lemierre syndrome except lacking internal jugular thrombosis. A review of the literature that forms the diagnostic criteria for this syndrome and the rationale for our creating this novel term is presented.

Lemierre's disease: a case with bilateral iliopsoas abscesses and a literature review

Lemierre's disease is characterized by sepsis, often with an oropharyngeal source, secondary septic emboli and internal jugular vein thrombosis (Lancet 1:701-3, 1936. Clin Microbiol Rev 20(4):622-59, 2007). Septic emboli affecting many bodily sites have been reported, including the lungs, joints, bones, and brain. The case report describes an unusual case of Lemierre's disease in a 64 year old gentleman causing profound sepsis, acute kidney injury, bilateral iliopsoas abscesses and a right hand abscess. To our knowledge, this is the first reported case of Lemierre's disease in the context of bilateral psoas abscesses, and highlights the ambiguity surrounding the definition of Lemierre's disease. The clinical literature review highlights the difficulty in definitively diagnosing the condition and offers some suggestions for recognising and refining the diagnostic criterion of Lemierre's.