Lemierre syndrome in a 22-month-old due to Streptococcus pyogenes: a case report

Respiratory Distress: Three Patient Cases

As mentioned in the January 2022 Pediatrics in Review Commentary, we now present three patients who have a common chief complaint followed by 5 questions for CME credit. All three cases have discussions on presentation, the differential diagnosis, and management that collectively serve as a Review article. The common theme here is that all three patients have difficulty breathing. We hope you will enjoy this review format.

Paralysis: A Rare Presentation of Lemierre's Syndrome: A Case Report

CASE

A patient presented with acute paralysis in the setting of undiagnosed Lemierre's syndrome. Streptococcus pyogenes was the causative organism leading to internal jugular vein thrombosis, sternocleidomastoid abscess, vertebral osteomyelitis, and epidural phlegmon. The patient was treated both surgically, with abscess evacuation, hemicorpectomy, and fusion, and medically, with antibiotics and anticoagulation. Postoperatively, the patient regained upper extremity strength and lower extremity sensation, but the paraplegia remained.

CONCLUSION

Lemierre's syndrome is a rare complication of oropharyngeal infection with a constellation of findings including jugular thrombophlebitis, metastatic abscesses, and frequent involvement of anaerobic pathogens that may present acutely with paralysis.

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.

Lemierre's syndrome caused by Streptococcus pyogenes in an elderly woman

Lemierre's syndrome is characterized by septic thrombophlebitis of the internal jugular vein. It typically presents in healthy adolescents or young adults, usually preceded by an oropharyngeal infection, with the most common offending pathogen being Fusobacterium necrophorum. We present a case of Lemierre's syndrome in an elderly woman without antecedent oropharyngeal infection, caused by Streptococcus pyogenes. She was successfully treated with combined surgical and medical management.

Antibiotic and Anticoagulation Therapy in Lemierre's Syndrome: Case Report and Review

Lemierre's syndrome is a rare and fatal disease and is also known as the forgotten disease to describe the rarity of this syndrome in the antibiotic era. However, in the last 20 years, the incidence of this disease has been increasing. Authors report a case of Lemierre's syndrome with extensive venous thrombosis involving right internal jugular veins with extension to the sigmoid and lateral sinus and also review the literature on the use of anticoagulant therapy in Lemierre's syndrome. A computerized Medline study was carried out through the use of PUBMED: using the Medical Subject Headings terms 'Lemierre Syndrome/diagnosis' and words 'Lemierre's syndrome and anticoagulation'. From this, authors found 64 articles from 2002 to January 2018 with a total of 165 patients. The purpose of our review is to emphasize that antibiotic therapy should be started immediately, while anticoagulant therapy should be started in selected cases. Anticoagulation should be carried out in absence of any contraindication or presumed risk following clinical anticoagulation guidelines and only in patients with poor clinical response despite antibiotics therapy, predisposing thrombophilia and intracranial thrombosis.

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.

Lemierre Syndrome Presenting as Acute Mastoiditis in a 2-Year-Old Girl with Congenital Dwarfism

Lemierre syndrome is defined by septic thrombophlebitis of the internal jugular vein caused by Fusobacterium. Historically, these infections originate from the oropharynx and typically are seen in older children, adolescents and young adults. More recently, otogenic sources in younger children have been described with increasing frequency. We present a case of a two-year old, who initially developed an otitis media with perforation of the tympanic membrane and went on to develop mastoiditis and non-occlusive thrombosis of the venous sinus and right internal jugular vein. Fusobacterium necrophorum was grown from operative cultures of the mastoid, ensuing computed tomography scan revealed occlusion of the internal jugular vein and the patient was successfully treated with clindamycin, ciprofloxacin and enoxaparin. This case demonstrates the importance of considering Fusobacterium in otogenic infections and the consideration of Lemierre syndrome when F. necrophorum is identified

Lemierre's syndrome with double heterozygote status in the methylenetetrahydrofolate reductase gene

BACKGROUND

There are some risk factors being more vulnerable to Lemierre's syndrome such as a hypercoagulable state.

METHODS

We report a rare case of Lemierre's syndrome with ethmoid and maxillary sinusitis, bilateral mastoiditis, and sigmoid sinus thrombosis.

RESULTS

Genetic study revealed a double heterozygote status in the methylenetetrahydrofolate reductase gene including C677T and A1298C.

CONCLUSION

It is suggested to screen patients with Lemierre's syndrome for a hypercoagulable state to consider anticoagulant therapy.