Lemierre's syndrome: current perspectives on diagnosis and management

A Rare Case of Lemierre's Syndrome due to Veillonella Parvula: A Dangerous and Forgotten Complication of a Septic Condition

This clinical case presents an unusual case of Lemierre's syndrome (LS) in a young woman of 38-year-old. She arrived in the Emergency Department with a high fever and pharyngology resistant to antibiotic therapy with clarithromycin, ceftriaxone, and cortisone for two weeks. At the blood sampling, there is a marked leucocytosis, and the advice of the otolaryngologist is required given the strong pain in the throat. Due to the tonsillar abscess, a neck CT with a contrast medium is necessary for the otolaryngologist's opinion. The CT shows thrombosis of the jugular vein and left subclavian, with thickening of soft perivascular tissues; these findings suggest Lemierre's syndrome: a septic thrombophlebitis of the jugular vein that occurs as a complication of a peritonsillar abscess. The diagnostic process is then completed with a chest HR-CT, which reveals lung density and excavation areas suggesting tuberculosis. Blood culture reveals the presence of Veillonella Parvula (an anaerobic gram-negative coccus), sputum culture reveals the presence of some colonies of Enterobacter cloacae complex, real-time PCR examination on sputum reveals the presence of Streptococcus Pneumoniae and the borderline presence of rhinovirus. Microbiologists, after these results and neck and chest CT with a contrast agent, agree with the diagnosis of suspected LS at an early stage: a septic dissemination fortunately limited only to the neck and lungs region.

Case Report: An Unusual Case of Lemierre's Syndrome Presenting as Influenza B-Induced Myositis Complicated by Streptococcus intermedius Infection

Lemierre's syndrome (LS) is a rare and severe complication primarily associated with the bacteria Fusobacterium necrophorum and characterized by an oropharyngeal infection leading to bacteremia and septic thrombophlebitis. We present a case of an 89-year-old patient with a history of hypertension who initially presented with type B influenza infection and neck pain. She subsequently developed a neck abscess with thrombosis of the internal jugular vein. We believe this to be the first reported case in the literature of LS secondary to Streptococcus intermedius presenting after infection with type B influenza. As more atypical LS cases emerge, it is becoming increasingly clear that this condition can manifest in a number of ways. This unique case highlights the importance of considering LS as a differential diagnosis for patients of all ages presenting with neck pain and Streptococcus intermedius infection.

Metagenomic next-generation sequencing reveals co-infection with Legionella pneumophila and Fusobacterium necrophorum in a patient with severe pneumonia: a case report

BACKGROUND

Legionella pneumonia is one of the most severe types of atypical pneumonia, impairing multiple organ systems, posing a threat to life. Diagnosing Legionella pneumonia is challenging due to difficulties in culturing the bacteria and limitations in immunoassay sensitivity and specificity.

CASE PRESENTATION

This paper reports a rare case of sepsis caused by combined infection with Legionella pneumophila and Fusobacterium necrophorum, leading to respiratory failure, acute kidney injury, acute liver injury, myocardial damage, and electrolyte disorders. In addition, we systematically reviewed literature on patients with combined Legionella infections, analyzing their clinical features, laboratory results and diagnosis.

CONCLUSIONS

For pathogens that require prolonged incubation periods and are less sensitive to conventional culturing methods, metagenomic next-generation sequencing (mNGS) can be a powerful supplement to pathogen screening and plays a significant role in the auxiliary diagnosis of complex infectious diseases.

Lemierre's Syndrome Secondary to Shoulder Hematoma Complicated by COVID-19: A Case Report

This case report illustrates a unique presentation of Lemierre's syndrome precipitated by Fusobacterium necrophorum. This case report describes a 20-year-old patient who developed Lemierre's syndrome secondary to a shoulder hematoma and neck abscess with multiple systemic complications in the absence of tonsillitis or oropharyngeal infection. Two weeks prior to presentation, the patient sustained a right shoulder injury and contracted COVID-19. Due to his Lemierre's syndrome, he developed right internal jugular vein and subclavian vein thrombosis, septic lung emboli, right sided Horner's syndrome, disseminated intravascular coagulation, pelvic collection, septic arthritis of pubic symphysis and osteomyelitis of the right pubic bone, and proximal left femoral shaft. The patient received non-operative and operative management to manage his Lemierre's syndrome including surgical drainage, antibiotics, and anticoagulation; he was discharged following an extended hospital stay. This case report highlights a rare presentation of Lemierre's syndrome secondary to a shoulder hematoma in a COVID-19 positive patient, and its potential systemic and life-threatening complications. Its importance is highly relevant in the context of the COVID-19 pandemic. Further studies are warranted to explore the effect of preceding COVID-19 infections on the microbiological profile in Lemierre's syndrome.

Surgical intervention of Lemierre's syndrome: a case report and review of the literature

BACKGROUND

Lemierre's syndrome is a fatal and rare disease that is typically characterized by oropharyngeal infection and internal jugular vein thrombosis. Timely institution of appropriate antibiotics is the standard treatment.

CASE PRESENTATION

The authors report a case of Lemierre's syndrome. A 67-year-old male patient of Han ethnicity in China suffered from a large inflammatory neck mass involving left internal jugular vein thrombosis diagnosed as Lemierre's syndrome and finally cured by surgical treatment. In addition, a literature review was carried out through PubMed using the terms "Lemierre's syndrome/disease and review, meta-analysis or retrospective study" and "Lemierre's syndrome/disease and internal jugular vein". This search yielded six articles that recorded surgical methods such as drainage, craniotomy, tooth extraction, and ligation of the occluded vein to give clinicians more ideas about the treatment of the Lemierre's syndrome.

CONCLUSION

This is the first review to summarize the conditions under which surgical treatment are conducted. Additionally, this is the first report of such a large inflammatory neck mass that was completely cured by surgical resection and internal jugular vein ligation. The authors also offer several conclusions regarding surgical intervention in Lemierre's syndrome for the first time.

Diagnostic and Therapeutic Challenges in Lemierre Syndrome: A Case Report Using Metagenomic Next Generation Sequencing

Lemierre syndrome (LS) is a rare and life-threatening condition predominantly caused by Fusobacterium necrophorum. Currently, there are no standardized clinical guidelines for LS management. Here, we describe the case of a 40-year-old male with fever, productive cough, and dyspnea but no sore throat. Diagnostic radiological examinations revealed multiple pulmonary cavitary nodules and an internal jugular vein occlusion. Metagenomic Next-Generation Sequencing (mNGS) of the alveolar lavage fluid identified Fusobacterium necrophorum, thereby confirming the diagnosis of LS. Intriguingly, the patient exhibited a delayed clinical response despite receiving the appropriate antibiotic. After integrating tigecycline into the treatment to address potential co-infecting bacteria, we observed a marked improvement in his clinical symptoms. Subsequent follow-up over 12 weeks post-discharge revealed complete alleviation of symptoms, and a chest CT scan showed marked regression of the lung lesions.

Lemierre's syndrome: A rare complication of acute bacterial pharyngitis

Lemierre's syndrome is a rare clinical syndrome of septic thrombophlebitis following a bacterial oropharyngeal infection. Lemierre's syndrome can be difficult to recognise and has significant morbidity. We report the case of a young man with Lemierre's syndrome caused by Streptococcus pyogenes, who responded well to 2 weeks of beta-lactam therapy.

Contributions

This case report summarises the key presenting features of Lemierre's syndrome and provides a brief literature review considering the South African context.

Atypical presentation of Lemierre's syndrome caused by penicillin-susceptible Staphylococcus aureus in a patient with chronic stomatitis and COVID-19

A healthy man in his late 20s was admitted to the emergency department due to a flare-up in his severe chronic stomatitis, along with flu-like symptoms. CXR showed multiple bilateral consolidations and subsequent CT revealed thrombosis of the left facial and internal jugular vein, together with septic embolism in both lungs. Blood cultures showed penicillin-susceptible Staphylococcus aureus The patient was diagnosed with Lemierre's syndrome, despite atypical bacteria and clinical presentation. During hospitalisation, he developed pulmonary empyema as a complication and was admitted for 4 weeks. During hospitalisation and after discharge, the patient was examined for multiple rheumatic, immunological and dermatological diseases, but no underlying cause for Lemierre's syndrome has been found. We present this case due to the rarity of its nature, with atypical clinical presentation and pathogen for Lemierre's syndrome, but with classic radiological findings.

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's Like Syndrome: Retropharyngeal Abscess With Internal Jugular and Cerebral Venous Thromboses and Septic Embolization Leading to Pulmonary Embolism and Cerebral Abscesses Complicated by Papilledema and Residual Sixth Cranial Nerve Palsy

A male child with a history of sinusitis presented to the emergency medicine department with a high fever, neck swelling, headache, vomiting, and double vision. He was diagnosed with retropharyngeal abscess (RPA) with bilateral internal jugular vein (IJV) and cerebral venous thromboses. The child was treated promptly and transferred to a specialty center, where the abscess was drained. However, he developed papilledema and septic embolism, leading to pulmonary embolism and cerebral abscesses. The child was an inpatient for six weeks and had outpatient treatment for three months. He developed exotropia due to bilateral sixth cranial nerve palsy. This existed even at the 24-month follow-up. This case report highlights the rare complications and morbidity from the retropharyngeal abscess. It also emphasizes the early diagnosis and management options in a busy emergency medicine department.

Lemierre-like syndrome after soft tissue infection due to methicillin-resistant Staphylococcus aureus: A case report and literature review

RATIONALE

Lemierre-like syndrome (LLS) is characterized by bacteremia, septic thrombophlebitis of the internal jugular vein, and metastatic abscesses. In contrast to classic Lemierre syndrome, sources of infection are not related to oropharyngeal infections, as are frequent soft tissue infections. In recent years, Staphylococcus aureus has been identified as an emergent pathogen that causes this syndrome. The mortality rate of LLS caused by this pathogen is approximately 16%. Timely diagnosis, antibiotic treatment, and infection control are the cornerstones to treat LLS. Anticoagulant therapy as adjuvant treatment remains controversial.

PATIENT CONCERNS

A 31-year-old woman from California, United States (US), was admitted to the emergency room with a history of 2 days of fever and severe throbbing pain in the left cervical region. Thorax and neck CT tomography revealed confluent cavities suggestive of septic embolism in the lungs and a filiform thrombus in the lumen of the left internal jugular vein, with moderate swelling of the soft and muscular tissues. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from the blood culture.

DIAGNOSIS

The thrombus in the internal jugular vein associated with cellulitis in the neck and multiple cavitary lesions in the lungs support the diagnosis of LLS caused by MRSA with septic embolization.

INTERVENTIONS

During treatment, the patient received vancomycin IV for 25 days and returned to the US with linezolid orally. In addition, assisted video-thoracoscopy and bilateral mini-thoracotomy with pleural decortication were performed for infectious source control, where 1700cc of purulent pleural fluid was drained.

OUTCOMES

The patient was discharged with optimal evolution.

LESSONS

LLS should be suspected in patients with skin and soft tissue infections who develop thrombosis or metastatic infections. MRSA infections should be considered in patients from areas where this pathogen is prevalent.

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.

Lemierre's Syndrome after Head and Neck Photoimmunotherapy for Local Recurrence of Nasopharyngeal Carcinoma

Introduction

Head and neck photoimmunotherapy (HN-PIT) uses a combination of drugs and laser illumination to specifically destroy tumor cells. Lemierre's syndrome is an infectious disease with severe systemic symptoms caused by prior infection in the pharyngeal region, leading to thrombophlebitis. Here, we report a case of Lemierre's syndrome that developed after HN-PIT for recurrent nasopharyngeal carcinoma.

Case Presentation

A 68-year-old male with nasopharyngeal carcinoma (squamous cell carcinoma) underwent HN-PIT after local recurrence with chemoradiation therapy. Three months after HN-PIT, the patient developed fever and neck pain, which led to a diagnosis of Lemierre's syndrome. The patient was treated with antibiotics and anticoagulants for at least 1 month. The patient's general condition and inflammatory findings on blood sampling showed gradual improvement, and a follow-up cervicothoracic computed tomography imaging showed that the venous thrombus had been obscured and the patient was doing well.

Conclusion

HN-PIT is a high-risk procedure for the development of Lemierre's syndrome due to irradiation-induced mucositis, and anticipating the development of Lemierre's syndrome during HN-PIT is important.

Lemierre Syndrome With Streptococcus constellatus Bacteremia

Lemierre syndrome is characterized by thrombophlebitis of the internal jugular vein (IJV) secondary to bacterial pharyngitis or tonsillitis. Though antibiotic use has made this a rarer syndrome, it can nevertheless manifest in patients presenting with pharyngitis. Herein, we describe a 20-year-old male patient with no relevant medical history presenting with signs concerning for pneumonia and was ultimately diagnosed with Lemierre syndrome with Streptococcus constellatus bacteremia. Complications included IJV thrombus with presumed septic emboli to the lungs. The patient was discharged on ampicillin/sulbactam with plans to transition to amoxicillin/clavulanate.

Lemierre's syndrome complicating deep neck abscess: a case report

BACKGROUND

Lemierre's Syndrome is a severe medical condition that can result from oropharyngeal infection, typically caused by Fusobacterium necrophorum, leading to sepsis, internal jugular vein thrombosis, and metastatic septic emboli. However, there is limited literature on this syndrome caused by Streptococcus anginosus, and few previous cases have been reported to have deep neck space infection. We present the first case of Lemierre's Syndrome caused by Streptococcus anginosus with deep neck abscess.

CASE PRESENTATION

A 53-year-old male patient with no significant medical history presented with right neck pain after accidentally swallowing a fish bone one month ago. Laryngoscopy did not reveal any abnormalities. Five days prior to admission, the patient developed high fever. Imaging studies showed internal jugular vein thrombosis and a neck abscess surrounding the carotid artery sheath. Blood culture results were positive for Streptococcus anginosus infection, and the patient was diagnosed with Lemierre's syndrome. The patient underwent surgical drainage and received antibiotics and anticoagulant therapy, and had satisfactory clinical progress. He was discharged after a 16-day hospitalization.

CONCLUSIONS

Although Lemierre's syndrome is rare, it needs attention because it can lead to serious complications and requires timely treatment. Deep neck space infections can be life-threatening and doctors must be aware of its potential severity.

Effects of Physical Therapy on a Patient With Lemierre's Syndrome Who Had Atelectasis and Limited Range of Motion in the Neck

Lemierre's syndrome (LS) is a severe infectious disease that can lead to the formation of neck abscesses and thrombosis. LS may be an indication for surgery; however, there are few reports on the physical therapy approaches used in patients with LS. A male patient in his 20s reported atelectasis and limited range of motion in the neck after resection of a deep neck abscess on the left side of the neck caused by LS. Thrombophlebitis was also observed around the neck lesion, indicating the risk of pulmonary embolism. Physical therapy was initiated with low-load, deep breathing exercises. Additional breathing exercises, such as respiratory assistance and positive pressure loading, were initiated after the administration of anticoagulants. Although the therapeutic intervention was delayed due to the unstable wound with partially resected muscle, it was assumed that the impairment of the range of motion in the neck was unlikely to persist as the patient was young. No critical adverse events were observed, and the range of motion was recovered such that the patient was able to resume playing baseball. The presence of a venous thrombus and inflammation may affect physical therapy; however, careful management of the exercise load could aid in the safe and effective treatment of LS without the incidence of complications, even in the early postoperative period.

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.

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.

A Previously Healthy Infant with Lemierre Syndrome in the Emergency Department: Case Report

INTRODUCTION

Lemierre syndrome (LS) is a rare condition with a high mortality risk. It is well described in older children and young adults involving bacteremia, thrombophlebitis, and metastatic abscess commonly due to Fusobacterium infections. Young, pre-verbal children are also susceptible to LS; thus, careful attention must be given to their pattern of symptoms and history to identify this condition in the emergency department (ED).

CASE REPORT

A 12-month-old previously healthy boy with a recent diagnosis of acute otitis media and viral illness presented to the ED with a complaint of fever. Additional symptoms developed at the head and neck and were noted on subsequent ED visits. Advanced imaging revealed significant lymphadenopathy and deep space inflammation extending to the mediastinum. Subsequent imaging confirmed extensive sinus and deep vein thromboses, consistent with LS. Methicillin-resistant Staphylococcus aureus (MRSA) was the only organism identified. After surgical debridement, appropriate intravenous antibiotics, and heparin anticoagulation therapy, the patient experienced full recovery after prolonged hospitalization.

CONCLUSION

A febrile infant with multiple acute care visits and development of lymphadenopathy, decreased oral intake, decreased cervical range of motion, and sepsis should raise suspicion for Lemierre syndrome. The medical evaluation of deep neck spaces and deep veins should be similar to that of older children and adults with LS, including advanced imaging of the head and neck. However, medical management should particularly target MRSA due to its emerging prevalence among infantile LS cases. Further research is necessary to determine the optimal management strategies of LS for this age group.

Lemierre's Syndrome Due to Streptococcus anginosus: A Case Report and Review of the Literature

Lemierre's syndrome, also known as anaerobic post-anginal septicemia, necrobacillosis, and the "forgotten disease," is a rare manifestation. It is often presented with sepsis, sore throat, fever, neck pain, internal jugular vein thrombophlebitis/thrombosis, and septic emboli. The bacteria that are usually associated with the disease are Fusobacterium species, but it is also associated with Staphylococcus, Streptococcus, and other bacterial species. The diagnosis of Lemierre's syndrome is made based on evidence of septic thrombophlebitis, preceding oropharyngeal infection, and positive culture. Treatment usually consists of antibiotics directed toward the causative organism. The use of anticoagulation, although controversial, is shown to be beneficial by several studies. We describe a middle-aged patient who presented with a sore throat, neck pain, and dysphagia. Imaging of the neck and chest revealed right jugular thrombosis along with septic emboli in the lungs. The culture of the blood and pus drained from the peritonsillar abscess grew Streptococcus anginosus. In this study, we have illustrated the effective management of Lemierre's syndrome with antibiotics, anticoagulants, and needle aspiration of abscess.

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.

Lemierre's Syndrome Associated With Papillary Thyroid Cancer and Cerebellar Stroke

A 53-year-old woman with no past medical history presented to the Emergency Department with right frontal headache and ipsilateral neck pain. She was found to have right internal jugular vein thrombosis, right cerebellar stroke, meningitis, septic pulmonary emboli, and fusobacterium bacteremia, all consistent with a severe presentation of Lemierre's syndrome (LS). While LS is often preceded by nasopharyngeal infection, no such history was elicited from our patient. Instead, concomitant papillary thyroid cancer with extension to her right internal jugular vein was implicated. Prompt recognition of these multiple related processes led to a timely initiation of appropriate therapy for infection, stroke, and malignancy.

Lemierre Syndrome: A Diagnosis behind the Veil

Lemierre syndrome (LS) is a rare, serious infection that is often misdiagnosed, as it frequently mimics common upper respiratory infections. It is even rarer for LS to be preceded by a viral infection. We share a case of LS in a young man who presented to the Emergency Department with COVID-19 viral infection followed by a subsequent LS diagnosis. The patient's condition initially worsened despite treatments for COVID-19 and was subsequently started on broad-spectrum antibiotics. He was then diagnosed with LS after blood cultures grew Fusobacterium necrophorum, and antibiotics were adjusted accordingly, resulting in improvement of symptoms. Even though LS is often recognized as a sequela of bacterial pharyngitis, preceding viral infections, including COVID-19, might be a risk factor that contributes to the development of LS.

Lemierre's Syndrome: A Lethal Complication of Acute Tonsillitis

Tonsillitis is a condition involving the infection of the lymphoid tissue of the tonsils. This pathology of the tonsils is frequently reported as a childhood illness in children of school-going age. The leading causative agent which is associated with tonsillitis is Group A and B Haemolytic Streptococcus and Staphylococcus and Haemophilus influenzae. With rapid and correct treatment and management with antibiotics and analgesics, it can be resolved, and the patient can be free of the symptoms such as sore throat, dysphagia, pain over the throat, and fever. Though in the minority of cases the diseases can progress and can result in multiple complications which sometimes can be lethal and extremely serious. These can be rheumatic fever, acute glomerulonephritis, or tonsillar cyst. One of the sporadic but equally important and grave syndromes is Lemierre's syndrome, which unfortunately has been labelled as a forgotten disease due to the development of antibiotic therapy and management of the disease. The mortality of the disease was extremely high in the pre-antibiotic era. This disease presents the following findings, such as thrombophlebitis of the internal jugular vein, which usually occurs after the presentation of pharyngeal infection. Which in later stages also gives rise to thrombi that advance and extend throughout the body, in the form of septic emboli. The important microorganism which is isolated and associated with the Lemierre's is Fusobacterium necrophorum, a strict gram-negative anaerobe. This article emphasizes and discusses the pathophysiology, and microbiology of Lemierre's syndrome. It also focuses on the clinical symptoms that include the appropriate and timely diagnosis and treatment of this deadly and fatal syndrome, together with the complications that arise with Lemierre's syndrome as the presenting problem.

Suppurative Thrombosis of the Portal Vein (Pylephlebits): A Systematic Review of Literature

Suppurative portal vein thrombosis (pylephlebitis) is an uncommon condition usually associated with an intra-abdominal infection or inflammatory process. In this study, we aimed to synthesize data on previously published cases according to the PRISMA guidelines. A total of 103 patients were included. Patients were more commonly male (71.8%) and had a mean age of 49 years. The most common infection associated with pylephlebitis was diverticulitis (n = 29, 28.2%), and Escherichia coli was the most isolated pathogen (n = 21, 20.4%). Blood cultures were positive in 64 cases (62.1%). The most common site of thrombosis was the main portal vein (PV) in 59 patients (57.3%), followed by the superior mesenteric vein (SMV) in 40 patients (38.8%) and the right branch of the PV in 30 patients (29.1%). Sepsis developed in 60 patients (58.3%). The mortality rate in our review was 8.7%, and independent risk factors for mortality were the presence of pertinent comorbidities (OR 5.5, p = 0.02), positive blood cultures (OR 2.2, p = 0.02), and sepsis (OR 17.2, p = 0.049).

A common complaint… a rare disease!

A 2-year-old previously well child presented to the emergency department with temperatures and lethargy. He was pale and looked unwell. He received a fluid bolus and was commenced on intravenous ceftriaxone. Pus was discharging from his left ear with postauricular swelling and erythema. Given clinical concerns, urgent neuroimaging was arranged.

Invasive Fusobacterium Infections in Children: A Retrospective Multicenter Study

BACKGROUND

The past decade has witnessed a rise in Fusobacterium infections. This study aimed to describe the epidemiology, clinical and demographic characteristics and outcomes associated with Fusobacterium infections in hospitalized children in central Israel.

METHODS

We retrospectively analyzed the medical records of children <18 years old who had been admitted with a diagnosis of invasive Fusobacterium infection (IFI) between January 2010 and April 2020. Clinical, laboratory and microbiologic data were retrieved. IFI diagnosis was based upon microbiological identification in any specimen by culture or by 16S ribosomal RNA polymerase chain reaction.

RESULTS

Fifty-one children (26 boys) with a median age of 3 years (range, 5-16 years) were included. Hospitalizations for IFI increased from 19 of 100,000 admissions between 2010 and 2015 to 50 of 100,000 between 2016 and 2020, representing a 2.5-fold increase. Most of the infections were from an otogenic source (n = 28, 55%) followed by an oropharyngeal/respiratory source (n = 21, 41%). The most common complications were subperiosteal and epidural abscesses (41% and 37%, respectively). Thrombosis was diagnosed in 11 children, 10 of whom had sinus vein thrombosis. All had an otogenic source. Children with otogenic compared with all other infection sources were significantly younger (median age of 1.9 vs. 3 years; P < 0.001). Forty-seven children (92%) underwent a surgical intervention. All patients survived, one with neurologic sequelae.

CONCLUSIONS

The admissions for IFI in children increased 2.5-fold during the last decade. The most common source is otogenic, especially among younger children, and it is associated with high complication rates. Current management, including combinations of antibiotics and surgical interventions, leads to favorable outcome.

Lemierre’s Syndrome with Facial Vein Thrombosis and Pulmonary Septic Emboli: A Case Report

Introduction: Lemierre’s syndrome (LS) is a rare and serious condition that often affects school-aged children, adolescents, and healthy young adults. It is defined as an oropharyngeal infection with secondary septicemia, internal jugular vein thrombosis, and septic emboli. Rare cases of atypical LS in which thrombosis occurs in other locations have been reported. Case Presentation: We presented a case of an adolescent with fever, sore throat, and neck tenderness. Physical examination revealed acute pharyngitis and bilateral small cervical lymph nodes. Rapid antigen group A Streptococcus and viral serologic tests were negative. Complete hemogram and blood biochemical analysis showed leukocytosis and elevated serum C-reactive protein (CRP). Cervical computerized tomography (CT) scan revealed a heterogeneous right tonsil and small cervical lymph nodes. The chest radiograph was normal. After admission, the adolescent started complaining of dyspnea and thoracic pain and had a painful small cervical right mass. In the thoracic CT angiography (CTA), several pulmonary septic emboli were apparent throughout the pulmonary parenchyma. Cervical Doppler ultrasound showed right facial vein thrombophlebitis, later confirmed in a CTA. Thromboses in other locations, including the internal jugular vein, were excluded, as well as cervical abscesses. The patient was successfully treated with intravenous antibiotic therapy and anticoagulation. Discussion: To this date, no reports of LS presenting with isolated thrombosis of the facial vein have been described in pediatric patients. We highlighted the importance of early recognition of LS and its atypical variants. Pediatric international guidelines regarding its management and treatment would also greatly affect the outcome of these patients.

Lemierre's Syndrome: A Comeback Story

Lemierre's syndrome is a very rare and life-threatening complication of bacterial pharyngitis and tonsillitis. Often referred to as a 'forgotten disease', Lemierre's syndrome has seen a rise in cases over the years secondary to increased antibiotic resistance. With the potential for multiple organ failure secondary to widespread septic emboli, Lemierre's syndrome can no longer be forgotten. Prompt initiation of treatment is needed for better patient outcomes. We describe an unusual case of a young female without any significant past medical history who presented with left-sided pleuritic chest pain several days after experiencing a sore throat.

The Role of Extracorporeal Blood Purification in the Treatment of a Patient with Lemierre's Syndrome

Lemierre's syndrome refers to the septic thrombophlebitis of the internal jugular vein. The condition typically begins with an oropharyngeal infection and frequently involves inflammation within the wall of the vein, infected thrombus within the lumen, surrounding soft tissue inflammation, persistent bacteremia, and septic emboli. Lemierre's syndrome is a rare disease; it occurs most commonly in otherwise healthy young adults. The most common etiologic agent is Fusobacterium necrophorum. We present a case of Lemierre's syndrome in a young girl and the role of extracorporeal method of blood purification with continuous venous hemodiafiltration with the use of a highly adsorptive membrane (AN69 HeprAN), thus achieving the combined elimination of cytokines and endotoxins. The use of advanced methods, along with an antibiotic and surgical treatment, will certainly help reduce mortality in this syndrome.

An Unusual Etiology of Lemierre-Like Syndrome: Preseptal Cellulitis due to Methicillin-Resistant Staphylococcus aureus

Lemierre’s syndrome (LS) is a rare and potentially fatal condition that predominantly affects young adults with oropharyngeal infection. Fusobacterium necrophorum is the usual etiology and classically causes internal jugular vein septic thrombophlebitis, frequently complicated by septic emboli to several organs (most classically to the lungs). Lemierre-like syndrome (LLS) describes the same constellation of symptoms and pathophysiology as Lemierre’s syndrome; however, Fusobacterium spp. are not the cause, and the source of infection may be nonoropharyngeal. We present a case with an unusual etiology of LLS: a patient with untreated preseptal cellulitis and associated methicillin-resistant Staphylococcus aureus (MRSA) bacteremia in the setting of injection drug use. Physical exam revealed tachypnea and rhonchi with severe periorbital and bilateral eyelid edema. Imaging demonstrated bilateral preseptal and orbital cellulitis with thrombosis of both internal jugular veins and bilateral pulmonary cavitary lesions consistent with septic pulmonary emboli. She was managed with anticoagulation and parenteral antibiotics. To our knowledge, this is the first case of LLS originating from preseptal cellulitis without evidence of preceding pharyngitis. While facial and orbital infections are rare etiologies of LLS, the potentially devastating sequelae of LLS warrant its inclusion in differential diagnoses.

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.

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.

Lemierre's syndrome complicated by cerebral venous sinus thrombosis: A life threatening and rare disease successfully treated with empiric antimicrobial therapy and conservative approach

Lemierre's syndrome (LS) is a "forgotten" condition characterized by septic thrombophlebitis of the jugular vein that follows an otolaryngological infection. Fusobacterium necrophorum is the aetiological agent responsible for the syndrome in adolescents and young adults whereas in older people even common bacteria are involved. Complications arise from spreading of septic emboli distally, i.e. to the brain, lungs, bones and internal organs everywhere in the body. We report a middle-aged woman who presented with headache and bilateral sixth cranial nerve palsy following a sphenoidal sinusitis and left mastoiditis. Imaging revealed thrombotic involvement of the left internal jugular vein as well as of several cerebral venous sinuses thrombosis (CVT). Currently, precise management protocols of LS with CVT complication do not exist although a combination of macrolides and second or third-generation cephalosporins, as well as anti-coagulants represent the mainstream of therapeutics. Surgical drainage is associated to remove septic foci but is burdened by severe complications and side effects. Complete recovery was achieved following pharmacological treatment in our patient. This report adds further evidence that LS complicated by CVT may be effectively treated adopting a conservative approach thus avoiding surgical drainage and severe complications.

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.

Odontogenic Lemierre's syndrome with septic superior ophthalmic vein and cavernous sinus thrombophlebitis complicated by blindness and ophthalmoplegia

Lemierre's syndrome is a triad consisting of oropharyngeal infection, internal jugular vein thrombophlebitis, and systemic embolisation typically involving lung and brain. Orbital involvement in this life-threatening condition is rare but potentially blinding and may be an indicator of intracranial involvement. We describe a case of odontogenic Lemierre's syndrome complicated by extensive orbital and intracranial septic venous thrombosis, with optic and cranial neuropathy resulting in monocular blindness and ophthalmoplegia. A multidisciplinary approach with abscess drainage, antibiotic and antithrombotic therapy, and close radiological monitoring was critical for preserving contralateral vision and neurological function.

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.

An atypical presentation of lemierre syndrome of urogenital source

Lemierre syndrome has classically been described as septic thrombophlebitis of the internal jugular veins resulting from primary oropharyngeal disease caused by Fusobacterium necrophorum. However, many cases have been reported of the syndrome originating from other primary sites of infection, resulting in limited utility of the diagnostic criteria and increased difficulty in making the diagnosis. We describe a 22-year-old female who developed the syndrome through a Fusobacterium infection which originated from a Bartholin gland abscess, a phenomenon that has not yet been described in the literature. Understanding and recognizing the variable forms of Lemierre syndrome allows us to better define the condition and provide optimal care to patients.

Anticoagulation may contribute to antimicrobial treatment of Lemierre syndrome: a case report

BACKGROUND

Lemierre syndrome (LS) is characterized by multisystemic infection beginning in the oropharynx, local thrombophlebitis (typically, of the internal jugular vein) and peripheral embolism. No evidence-based guidelines exist for the management of this disease, and the use of anticoagulation therapy remains particularly controversial.

CASE PRESENTATION

A 61-year-old man presenting with left neck swelling, odynophagia, and dyspnea underwent emergency surgery and received intravenous antibiotics. The primary infection was controlled on hospital day 5, but on day 6 sudden leukocytosis and hypoxemia were observed. CT angiography revealed an intraluminal filling defect in the pulmonary artery on day 8. LS was diagnosed and anticoagulation therapy was initiated. The WBC count, which had maintained its peak values in the previous 2 days, decreased instantly after initiation, and follow-up controls showed thrombus resolution.

CONCLUSIONS

Our case supports the notion that anticoagulation therapy may be a valid supplement to antimicrobial therapy in LS, especially in the presence of a possibly young thrombus as suggested by clinical worsening.

Pediatric Patient with Lemierre Syndrome of the External Jugular Vein: Case Report and Literature Review

Introduction  Lemierre syndrome (LS) involving the external jugular vein (EJV) is rare, and only a few cases have been reported in the literature. Objectives  To report a case of LS involving the external jugular vein as well as to make a review of the literature regarding both diagnosis and management strategies. Data Synthesis  We describe a case of LS involving the EJV and review the literature of previously published articles to search for additional cases. A PubMed, Embase, Scopus, and Web of science-based search was performed to determine the scope of coverage in well-reported articles in English. Twenty-one papers were retrieved and documented for age, incidence, pathogen, presenting symptoms, imaging, treatment, and outcome, which were noted for each of these cases. In our literature review of 21 papers, there were 16 patients (61%) in their 2nd and 3rd decades of life. Lemierre syndrome was shown to affect females and males equally. The presenting symptoms were a sore throat and fever. Treatment requires intravenous antibiotics, and there is no consensus regarding treatment with anticoagulation. Conclusions  The present case report and review of the literature emphasize the importance of history taking as well as physical examination in what seems to be a case of simple tonsillitis.

Lemierre's syndrome caused by Klebsiella pneumoniae: A case report

BACKGROUND

Lemierre's syndrome is a disease that causes anaerobic sepsis, internal jugular vein thrombosis, and septic embolism in the lungs and other organs after acute oropharyngeal infection. It was named after André-Alfred Lemierre in 1936.

CASE SUMMARY

Here, we have reported a case of Lemierre’s syndrome in a 56-year-old female patient who presented with a sore throat. The patient had septic shock, had not voided, and had severe hyperglycemia at the time of her visit. Imaging tests revealed bilateral pneumonia, pleural effusion, pulmonary embolism, and renal vein thrombosis. The patient was admitted to the intensive care unit and placed on mechanical ventilation due to acute respiratory distress syndrome. Continuous renal replacement therapy was administered to treat renal failure with anuria. Klebsiella pneumoniae was cultured from blood and sputum samples. After reviewing various results, the patient was ultimately diagnosed with Lemierre’s syndrome. The patient was treated with appropriate antibiotics and thrombolytic agents. She was discharged from the hospital after recovery.

CONCLUSION

Lemierre’s syndrome is associated with a high mortality rate. Therefore, clinicians should be familiar with the signs and symptoms of this disease as well as the preemptive examinations, procedures, and treatments.

Lemierre Syndrome in a Patient With Splenectomy Secondary to Pyruvate Kinase Deficiency, Complicated by Heparin Resistance

Lemierre syndrome was first documented in the literature in 1936, and is defined as septic thrombophlebitis of the internal jugular vein. It is typically a result of oropharyngeal infection causing local soft tissue inflammation, which spreads to vasculature, and promotes formation of septic thrombi within the lumen, persistent bacteremia, and septic emboli. We present the case of a 24-year-old incarcerated man, who presented with leukocytosis and a right-sided tender, swollen neck after undergoing left mandibular molar extraction for an infected tooth. Computed tomography revealed a persistent thrombus in the transverse and sigmoid sinuses bilaterally, extending downwards, into the upper jugular veins. He was started on empiric intravenous vancomycin, zosyn, and heparin, but subsequently demonstrated heparin resistance, and was thus anticoagulated with a lovenox bridge to warfarin. Throughout his hospital course, hemocultures demonstrated no growth, so antibiotic treatment was deescalated to oral metronidazole and ceftriaxone. On discharge, the patient was transitioned to oral amoxicillin and metronidazole for an additional 4 weeks with continuation of anticoagulation with warfarin for a total of 3 to 6 months. This case report details a unique presentation of Lemierre syndrome with bilateral transverse sinus, sigmoid sinus, and internal jugular vein thrombosis that was presumably secondary to an odontogenic infectious focus.