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.

Bilateral pterygoid abscesses in a patient with Lemierre's syndrome

Patients with Lemierre's syndrome may have complications such as lung lesions, large joint arthritis and central nervous system involvement. However, complications involving a pterygoid abscess have scarcely been reported. Here, we report a case of bilateral Lemierre's syndrome accompanied with an intracranial epidural abscess and bilateral pterygoid abscesses. A woman in her 70s presented to the emergency room with a decreased level of consciousness. Infection was suspected, and Slackia exigua and species of Fusobacterium were identified in blood cultures, which suggested that the origin of infection was odontogenic, particularly as the patient had poor oral hygiene. Head and neck CT with contrast enhancement revealed bilateral internal jugular vein thrombophlebitis, septic pulmonary embolism, frontal epidural abscess and bilateral pterygoid abscesses. After antibiotic treatment and drainage, her condition improved. Pterygoid abscesses should be recognised as a rare complication of Lemierre's syndrome, especially when the infection origin is odontogenic.

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.

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.

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.

Anticoagulation Strategies in the Management of Lemierre Syndrome: A Systematic Review of the Literature

OBJECTIVE

To determine the optimal anticoagulation strategy in patients diagnosed with Lemierre Syndrome (LS).

DATA SOURCES

A systematic review in accordance with PRISMA guidelines was conducted using PubMed, MEDLINE, Scopus, ProQuest, and CINAHL from January to April 2020. Search terms included "Lemierre Syndrome" AND "anticoagulation" NOT "prophylaxis" OR "atrial fibrillation," in addition to a list of parenteral and oral anticoagulants. Adult patients who developed a clot and required systemic anticoagulation as a result of LS were included in this review.

STUDY SELECTION AND DATA EXTRACTION

A total of 4180 records were initially identified, though following the removal of duplicates and nonrelevant entries, 216 full-text articles were reviewed for inclusion; 13 articles were ultimately included.

DATA SYNTHESIS

The majority (11/14) of patients developed thromboses of the internal jugular veins, which corresponds to the pathophysiology of LS. Anticoagulation strategies were varied in the included literature, though 12/14 patients initially received a parenteral product. Two patients received a direct-acting oral anticoagulant (DOAC) following either intravenous heparin or subcutaneous enoxaparin and had outcomes similar to patients transitioned to warfarin.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Anticoagulation in LS is a clinical controversy because the thromboembolic events have rarely led to significant complications; thrombi typically resolve independently, and concerns for bleeding risks are well founded; however, this review indicates both the efficacy and safety of anticoagulation.

CONCLUSIONS

Anticoagulation is both efficacious and safe in LS, including treatment using a DOAC. Although further studies are needed, clinicians should consider a duration of anticoagulation of 6 to 12 weeks.

Cavernous sinus thrombosis caused by Streptococcus constellatus-associated Lemierre syndrome presenting as an isolated abducens nerve palsy

Purpose

To describe a patient with Streptococcus constellatus-associated Lemierre syndrome complicated by eventual cavernous sinus thrombosis (CST) that manifested as an isolated abducens nerve palsy.

Observations

A patient with a history of heavy alcohol use presented with Lemierre syndrome caused by an odontogenic infection due to Streptococcus constellatus. Despite initiation of intravenous antibiotics and eventual eradication of her bacteremia, she developed an isolated abducens nerve palsy on hospital day 7 due to associated CST.

Conclusions and Importance

CST is a rare complication of odontogenic infection and Lemierre syndrome. This case demonstrates the potential for primary odontogenic infections to progress to life- and sight-threatening diseases. This case also illustrates the importance of considering uncommon pathogens as the etiology of CST based on the suspected source of primary infection.

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.

Human Infection with Fusobacterium necrophorum without Jugular Venous Thrombosis: A Varied Presentation of Lemierre's Syndrome

Lemierre's syndrome is also known as postangina septicemia, which is commonly caused by Fusobacterium necrophorum also known as Necrobacillus and also by other microorganisms like Staphylococcus, Streptococcus, Peptostreptococcus, and Bacteroides. Though the disease starts as an upper respiratory tract infection, it may spread and cause thrombophlebitis of the internal jugular vein. It may present itself through cranial nerve palsy or sepsis involving distant organs like the lungs or bones. It is also known as forgotten disease because of its rarity. Fusobacterium necrophorum usually causes infection in animals and rarely affects humans. We hereby present a case of Necrobacillus infection which did not cause any thrombophlebitis but resulted in severe pneumonia and acute kidney injury, leading to respiratory failure and requiring mechanical ventilation.

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; a rare cause of septic arthritis

Lemierre's syndrome is a rare condition characterised by pharyngitis leading to septic thrombophlebitis of the internal jugular vein. Complications include pulmonary septic emboli, septic arthritis and disseminated intravascular coagulation. The authors present a case of a healthy woman aged 25 years with septic arthritis of the shoulder due to this unusual cause. This diagnosis was made via a combination of clinical, radiological and microbiological findings. It was successfully treated via surgical and antimicrobial interventions. The patient made a good recovery with minimal associated morbidity or loss of function. This case highlights the importance for awareness and high index of suspicion for rarer causes of septic arthritis in young healthy adults as early appropriate intervention maximises prognosis.

Lemierre's syndrome: a serious complication of a routine dental procedure

Lemierre's syndrome is the clinical presentation characterized by oropharyngeal or tonsillar infection, anaerobic septicaemia often with distant septic emboli, and clinical or radiological evidence of thrombosis of the internal jugular vein. We report a case of Lemierre's syndrome in a 44-year-old type II diabetic male. This case is unique for two reasons. Firstly, we believe it is the first reported iatrogenic case following a routine dental procedure. Secondly, the internal jugular vein thrombosis was found to occur on the contralateral side to the primary infection.

Bilateral lemierre syndrome secondary to periodontitis: a case report and review of the literature

BACKGROUND

Lemierre syndrome is the typical presentation of human necrobacillosis. It is characterized by an initial infection, progressing to septic thrombophlebitis, septicemia, and multisystem embolic necrotic abscesses. It is usually caused by Fusobacterium necrophorum, but its pathophysiology remains obscure. A case of bilateral Lemierre syndrome secondary to periodontitis is reported.

CASE PRESENTATION

A previously healthy 24-year-old African American man presented with a 2-week history of fever, chills, dyspnea, abdominal pain and vomiting, nonbloody diarrhea, anorexia, and body aches. He occasionally smoked marijuana but had no pets, and denied sick contact or recent travel. Physical examination was remarkable for tachypnea, tachycardia, pyrexia, icteric sclera, dry oral mucosa, moderate-to-severe gingival inflammation, and dental caries involving the upper and lower molars. The oropharynx was clear. He had tenderness over the sternocleidomastoid muscles bilaterally, and nontender cervical lymphadenopathy. Chest examination revealed reduced breath sounds in both bases with fine crackles at the right base. Examination of the cardiovascular and gastrointestinal systems was significant for tenderness in the right upper quadrant with no rebound. Laboratory findings were significant for leukocytosis with a left shift, anemia, abnormal liver function tests, elevated creatine phosphokinase, and positive blood culture for F. necrophorum. Chest radiographs and computed tomography scans revealed multilobar cavitary nodular densities with pleural effusions. Duplex sonography of the neck demonstrated thrombosed left internal jugular vein with complete occlusion of the lumen, thrombosed left subclavian, and axillary veins with minimal blood flow. There was also a small thrombus in both the right internal jugular and right subclavian veins with partial occlusion of their lumina. He was prescribed penicillin, metronidazole, and anticoagulation therapy and had complete resolution of the lung lesions and marginal improvement of the bilateral neck thrombophlebitis. He was awaiting dental procedures.

CONCLUSIONS

A case is reported of extensive bilateral septic thrombophlebitis of the deep neck veins secondary to periodontal disease. To the best of my knowledge, this is the first case of bilateral Lemierre syndrome due to periodontal disease reported in the literature. It highlights the typical septic thrombophlebitis of Lemierre syndrome and its protean manifestations, such as hepatitis and rhabdomyolysis. This presentation also underscores the significance of thorough dental examinations in febrile patients. With respect to anticoagulation therapy in Lemierre syndrome, though still not established, there is some evidence of utility with no untoward effects.

Methicillin-resistant Staphylococcus aureus USA300 clone as a cause of Lemierre's syndrome

We describe a case of a young woman who had methicillin-resistant Staphylococcus aureus USA300 clone (MRSA-USA300)-associated Lemierre's syndrome and secondary necrotizing pneumonia and cerebral infarcts. We also review 11 cases of S. aureus-associated Lemierre's syndrome reported in the literature from 1965 to 2010. Recognition of S. aureus as an emergent cause of Lemierre's syndrome informs the initial empirical antibiotic choice for this life-threatening condition and may positively impact patient outcomes.

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.

Eponym: the Lemierre syndrome

Fig. 1 Dr. Andre Lemierre Lemierre syndrome, also known as postanginal sepsis, is a severe complication of an acute oropharyngeal infection that results in septic thrombophlebitis of the ipsilateral internal jugular vein with subsequent septicemia, often complicated by metastatic infections. The usual agent in Lemierre syndrome is Fusobacterium necrophorum, a commensal bacillus of the oral cavity. After the advent of antibiotic therapy, especially in the 1960s and 1970s, when penicillin was frequently used to treat pharyngeal infections, Lemierre syndrome was often referred to as the "forgotten disease". Today with increasing antibiotic-resistant organisms and decreasing awareness of the syndrome, subsequent reemergence of this syndrome is becoming more common in clinical settings. The syndrome starts initially as an acute oropharyngeal infection followed by septicemia with intense fevers, rigors, swelling, and tenderness on the lateral aspect of the neck, parallel to the sternomastoid muscle (septic internal jugular vein thrombophlebitis), and multiple metastatic infections.

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.

A sore throat--potentially life-threatening?

A sore throat, which is most commonly viewed as a minor ailment, can be a manifestation of a life-threatening disorder known as Lemierre's syndrome caused by Fusobacterium necrophorum. We report a new case of Lemierre's syndrome that occurred in an otherwise healthy 18-year-old woman, who initially presented with fever and sore throat. The diagnosis was not made until a week later when blood cultures became available. This syndrome should be suspected until proven otherwise in any patient with signs of pharyngitis, a painful swollen neck, and pulmonary symptoms. By presenting this curable, but potentially life-threatening case of Lemierre's syndrome, we hope to increase the awareness of the early clinical manifestations of Lemierre's syndrome and to emphasize the importance of careful physical examination with special attention to the neck. Clinicians should be aware that exclusion of streptococcal infection in a patient with severe tonsillar infection does not exclude a bacterial cause.

Infection by Panton-Valentine leukocidin-producing Staphylococcus aureus clinically mimicking Lemierre's syndrome

Lemierre's syndrome is an oropharyngeal infection which leads to severe septic thrombophlebitis of the internal jugular vein and metastatic abscesses of the lungs and other organs. It is usually caused by Fusobacterium necrophorum, a Gram-negative obligate anaerobe. An unusual case of Panton-Valentine leukocidin (PVL)-producing Staphylococcus aureus infection masquerading as Lemierre's syndrome is reported here. A 32-year-old fit and otherwise healthy male presented on Christmas morning with a boil on his left cheek for 2 days and generalized rash for 3 h. His general condition began to worsen, he developed facial swelling and loss of vision in the left eye and was transferred to the intensive care unit. His treatment was taken over by team of specialists and further investigations revealed thrombophlebitis of the left internal jugular vein and cavernous sinus thrombosis with multiple brain infarcts and lung abscesses. His condition remained critical with multiple cranial nerve involvement despite being on broad-spectrum antibiotics. Blood cultures grew S. aureus which was producing PVL toxin. He improved gradually over several weeks. He underwent intensive physiotherapy and made a good recovery. Although a rare entity, it is important to consider Lemierre's syndrome in septic patients who present with rapidly worsening symptoms.

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.

Lemierre’s syndrome: A potentially fatal complication that may require vascular surgical intervention

Septic phlebitis of the internal jugular vein, Lemierre's syndrome, is extremely rare. However, Lemierre's syndrome may cause septic pulmonary emboli or result in fatal systemic sepsis, or both, if a timely diagnosis and appropriate treatment are not provided. We present a case of Lemierre's syndrome that occurred in an otherwise healthy young man. In this case, progression to a moribund state was rapid, and surgical intervention proved lifesaving.

Un cas de syndrome de Lemierre avec thrombose veineuse jugulaire bilatérale

An adolescent presented with a rhinosinusitis complicated with bilateral jugular veins and left superior ophthalmic vein thrombosis and respiratory distress with pulmonary hypertension. Blood culture was positive for Haemophilus influenzae and sinus puncture for Streptococcus constellatus. Evolution was under control after 1 week of appropriate antibiotherapy, antithrombotic and anti-inflammatory treatment. He had no neurologic, respiratory or ophthalmologic sequelae 6 months later. Despite lack of pharyngitis or isolation of anaerobic species on blood cultures, the picture was considered compatible with Lemierre syndrome. The risk for such a complication should be considered in cases of severe otorhinolaryngologic infection in young adults.

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.