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George E, Callen AL, Glastonbury CM. Atypical thrombophlebitis patterns in head and neck infections. Neuroradiol J 2023; 36:760-765. [PMID: 36912438 PMCID: PMC10649533 DOI: 10.1177/19714009231163564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
Thrombophlebitis is a known complication of head and neck infection, which can result in propagation of infected thrombi and associated complications. While antegrade/downstream propagation of thrombus is well described-the Lemierre syndrome-thrombophlebitis can spread in atypical patterns which has specific diagnostic and treatment considerations. In this series, we highlight 6 cases of atypical thrombophlebitis patterns complicating head and neck infection, 5 of which extend intracranially. Through these pathways, head and neck infections such as oral cavity, oropharynx, or skin can be the culprit of remote, including intracranial, complications, which may be overlooked. Furthermore, understanding pathways of venous drainage and communication can help accurately diagnose thrombophlebitis patterns and associated complications.
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Affiliation(s)
- Elizabeth George
- Department of Radiology and Biomedical Imaging, University of California San Francisco, USA
| | - Andrew L Callen
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, CO USA
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Kreuzpointner R, Valerio L, Corsi G, Zane F, Sacco C, Holm K, Righini C, Pecci A, Zweifel S, Barco S. Ophthalmic complications of Lemierre syndrome. Acta Ophthalmol 2022; 100:e314-e320. [PMID: 33829646 DOI: 10.1111/aos.14871] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 03/03/2021] [Accepted: 03/16/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE Lemierre syndrome is a life-threatening condition characterized by head/neck bacterial infection, local suppurative thrombophlebitis and septic embolic complications in a range of sites of distant organs. No prior study focused on the course and characteristics of ophthalmic complications of Lemierre syndrome. METHODS We analysed data of 27 patients with ophthalmic complications from a large cohort of 712 cases with Lemierre syndrome reported globally between 2000 and 2017. We focused on initial manifestations, early (in-hospital) course and long-term ophthalmic deficits at the time of hospital discharge or during postdischarge follow-up. The study protocol was registered in the International Prospective Register of Systematic Reviews PROSPERO (CRD42016052572). RESULTS Nine (33%) patients were women; the median age was 20 (Q1-Q3: 15-33) years. Fusobacterium spp. was involved in 56% of cases. The most prevalent initial manifestations were decreased vision (35%) and periocular oedema (38%), followed by impaired eye movements/nerve palsy (28%) and proptosis (28%). Venous involvement, notably cerebral vein thrombosis (70%) and ophthalmic vein thrombosis (55%), explained the symptomatology in most cases. Septic embolism (7%), orbital abscesses (2%) and carotid stenosis (14%) were also present. Ophthalmic sequelae were reported in 9 (33%) patients, often consisting of blindness or reduced visual acuity, and nerve paralysis/paresis. CONCLUSION Ophthalmic complications represent a severe manifestation of Lemierre syndrome, often reflecting an underlying cerebral vein thrombosis. Visual acuity loss and long-term severe complications are frequent. We call for an interdisciplinary approach to the management of patients with Lemierre syndrome and the routine involvement of ophthalmologists.
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Affiliation(s)
| | - Luca Valerio
- Center for Thrombosis and Hemostasis University Medical Center Mainz Mainz Germany
| | - Gabriele Corsi
- Department of Clinical, Integrated and Experimental Medicine (DIMES) Alma Mater Studiorum University of Bologna Bologna Italy
- Department of Pneumology and Respiratory Intensive Therapy Unit St Orsola University Hospital Bologna Italy
| | - Federica Zane
- Department of General Medicine Hospital of Sondrio Sondrio Italy
| | - Clara Sacco
- Thrombosis and Haemorrhagic Diseases Center Humanitas Clinical and Research Center‐IRCCS Milan Italy
| | - Karin Holm
- Department of Clinical Sciences Division of Infection Medicine Skåne University Hospital Lund University Lund Sweden
| | - Christian Righini
- Department of ENT, Head and Neck Surgery University Hospital of Grenoble Grenoble France
| | - Alessandro Pecci
- Department of Internal Medicine IRCCS Policlinico San Matteo Foundation and University of Pavia Pavia Italy
| | - Sandrine Zweifel
- Department of Ophthalmology University Hospital Zurich Zurich Switzerland
- University of Zurich Zurich Switzerland
| | - Stefano Barco
- Clinic of Angiology University Hospital Zurich Zurich Switzerland
- Center for Thrombosis and Hemostasis University Medical Center Mainz Mainz Germany
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Klug TE, Greve T, Hentze M. Complications of peritonsillar abscess. Ann Clin Microbiol Antimicrob 2020; 19:32. [PMID: 32731900 PMCID: PMC7391705 DOI: 10.1186/s12941-020-00375-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 07/24/2020] [Indexed: 12/12/2022] Open
Abstract
Background The vast majority of patients with peritonsillar abscess (PTA) recover uneventfully on abscess drainage and antibiotic therapy. However, occasionally patient´s condition deteriorates as the infection spread in the upper airway mucosa, through cervical tissues, or hematogenously. The bacterial etiology of PTA is unclarified and the preferred antimicrobial regimen remains controversial. The current narrative review was carried out with an aim to (1) describe the spectrum of complications previously recognized in patients with peritonsillar abscess (PTA), (2) describe the bacterial findings in PTA-associated complications, and (3) describe the time relation between PTA and complications. Methods Systematic searches in the Medline and EMBASE databases were conducted and data on cases with PTA and one or more complications were elicited. Results Seventeen different complications of PTA were reported. The most frequently described complications were descending mediastinitis (n = 113), para- and retropharyngeal abscess (n = 96), necrotizing fasciitis (n = 38), and Lemierre´s syndrome (n = 35). Males constituted 70% of cases and 49% of patients were > 40 years of age. The overall mortality rate was 10%. The most prevalent bacteria were viridans group streptococci (n = 41, 25%), beta-hemolytic streptococci (n = 32, 20%), F. necrophorum (n = 21, 13%), S. aureus (n = 18, 11%), Prevotella species (n = 17, 10%), and Bacteroides species (n = 14, 9%). Simultaneous diagnosis of PTA and complication was more common (59%) than development of complication after PTA treatment (36%) or recognition of complication prior to PTA (6%). Conclusion Clinicians involved in the management of PTA patients should be aware of the wide range of complications, which may arise in association with PTA development. Especially males and patients > 40 years of age seem to be at an increased risk of complicated disease. In addition to Group A streptococci and F. necrophorum, the current findings suggest that viridans group streptococci, S. aureus, Prevotella, and Bacteroides may also play occasional roles in the development of PTA as well as spread of infection. Complications occasionally develop in PTA patients, who are treated with antibiotics and surgical drainage.
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Affiliation(s)
- Tejs Ehlers Klug
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99 Aarhus N, Aarhus, 8200, Denmark.
| | - Thomas Greve
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Malene Hentze
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99 Aarhus N, Aarhus, 8200, Denmark
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Dasari SP, Jha P. A Systematic Review of Lemierre's Syndrome With a Focus on Ophthalmologic Complications. Cureus 2020; 12:e9326. [PMID: 32742884 PMCID: PMC7384458 DOI: 10.7759/cureus.9326] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Lemierre's syndrome (LS), once known as "the forgotten disease," is a rare and potentially life-threatening condition that has had a gain in incidence over the last 30 years due to a variety of factors that could include changes in antibody prescription patterns, particularly in regard to the treatment of pharyngitis/tonsillitis. Due to its low incidence and broad spectrum of symptoms, LS does not have an obvious clinical diagnosis and can confuse the clinician managing the patient. Furthermore, it is equally difficult to treat patients suffering from LS as it requires a multidisciplinary approach from multiple subspecialties. Thus, communication between hospitalists, radiologists, otolaryngologists, neurologists, and ophthalmologists is critical towards quickly diagnosing the disease condition so that prompt antibiotics, anticoagulation, and surgical intervention can occur. Atypical presentations can also exist, making the diagnosis and management exponentially more challenging. Ophthalmologic symptoms are a particularly rare and atypical presentation of LS. These rare symptoms in LS can be terrifying for patients and providers alike; yet, there does not seem to be any modern medical literature that summarizes ophthalmologic complications for LS patients. To our knowledge, this is the first systematic review of LS with a focus on ophthalmologic complications that has been done. The main objective of this review paper is to provide an up-to-date literature review of LS epidemiology, pathophysiology, diagnosis, and treatment while also performing a novel systematic review of reported cases of LS with ophthalmological complications. We hope to bring more awareness towards LS and its atypical presentations so that physicians will be better able to rapidly diagnose and treat their patients in order to minimize long-term morbidity and mortality.
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Affiliation(s)
- Suhas P Dasari
- Internal Medicine, Medical College of Wisconsin, Wauwatosa, USA
| | - Pinky Jha
- Internal Medicine, Medical College of Wisconsin, Wauwatosa, USA
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Rahimi D, Langkilde AR, Iversen HK, Truelsen TC. Lemierre's syndrome with stroke and stenosis of the internal carotid artery suggesting focal vasculitis. J Neurol Sci 2020; 409:116632. [DOI: 10.1016/j.jns.2019.116632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 12/06/2019] [Accepted: 12/10/2019] [Indexed: 11/29/2022]
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Rohowetz LJ, Gratton SM, Dansdill D, Miller CJ, Dubin S. Cavernous sinus thrombosis caused by Streptococcus constellatus-associated Lemierre syndrome presenting as an isolated abducens nerve palsy. Am J Ophthalmol Case Rep 2020; 18:100592. [PMID: 32123771 PMCID: PMC7037586 DOI: 10.1016/j.ajoc.2020.100592] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 12/15/2019] [Accepted: 01/02/2020] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | - Sarah Dubin
- Corresponding author. Department of Internal Medicine University of Missouri, Kansas City 2411 Holmes St, Kansas City, MO, 64108, USA.
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Campo F, Fusconi M, Ciotti M, Diso D, Greco A, Cattaneo CG, de Vincentiis M. Antibiotic and Anticoagulation Therapy in Lemierre's Syndrome: Case Report and Review. J Chemother 2019; 31:42-48. [PMID: 30773133 DOI: 10.1080/1120009x.2018.1554992] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Flaminia Campo
- a Department of Sensory Organs , University ''Sapienza'' of Rome , Rome, Italy
| | - Massimo Fusconi
- a Department of Sensory Organs , University ''Sapienza'' of Rome , Rome, Italy
| | - Mario Ciotti
- b Department of Radiotherapy , ENT Special Service of Radiology, University ''Sapienza'' of Rome , Rome, Italy
| | - Daniele Diso
- c Department of Thoracic Surgery , 'Sapienza' University of Rome , Rome , Italy
| | - Antonio Greco
- a Department of Sensory Organs , University ''Sapienza'' of Rome , Rome, Italy
| | | | - Marco de Vincentiis
- a Department of Sensory Organs , University ''Sapienza'' of Rome , Rome, Italy
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Johannesen KM, Bodtger U. Lemierre's syndrome: current perspectives on diagnosis and management. Infect Drug Resist 2016; 9:221-227. [PMID: 27695351 PMCID: PMC5028102 DOI: 10.2147/idr.s95050] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
This is a systematic review of cases with Lemierre’s syndrome (LS) in the past 5 years. LS is characterized by sepsis often evolving after a sore throat or tonsillitis and then complicated by various septic emboli and thrombosis of the internal jugular vein. Symptoms include sepsis, pain, and/or swelling in the throat or neck, as well as respiratory symptoms. Laboratory findings show elevated infectious parameters and radiological findings show thrombosis of the internal jugular vein and emboli in the lungs or other organs. The syndrome is often associated with an infection with Fusobacterium necrophorum. We found a total of 137 cases of LS, of which 47 were infected with F. necrophorum and others with Staphylococcus and Streptococcus. Complications of this rare but severe disease included osteomyelitis, meningitis, and acute respiratory distress syndrome. Mortality was extremely high in the pre-antibiotic era but has diminished with the advent of antibiotics. This review showed a mortality rate of only 2% of which none of the cases involved fusobacteria. Duration of treatment varied; a 4–6-week course of carbapenem or piperacillin/tazobactam in combination with metronidazole was optimum. Other treatment options included anticoagulants in 46% of cases, which is unwarrantedly high, as to date, no evidence of the positive effects of anticoagulants in LS exists. Only two cases had ligation of the internal jugular vein performed. This review confirms the rare, but severe aspects of LS. Mortality from LS in this day and age appears to be low, however the syndrome is difficult to recognize, and still requires the full attention of the clinician.
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Affiliation(s)
| | - Uffe Bodtger
- Department of Lung Medicine, Naestved Hospital, Naestved; Institute for Regional Health Research, University of Southern Denmark, Odense; Department of Pulmonology, Zealand University Hospital, Roskilde, Denmark
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Kageyama K, Watanuki Y, Terui K, Endo K, Daimon M. A Case of Acute Suppurative Thyroiditis Accompanied by Transient Abducens Nerve Palsy. AACE Clin Case Rep 2016. [DOI: 10.4158/ep15788.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Nishida A, Ogata T, Kudo M, Fukuhara K, Fukae J, Tsuboi Y. [A case with both infectious cavernous sinus thrombosis and Lemierre syndrome due to intraoral resident flora]. Rinsho Shinkeigaku 2015; 55:483-9. [PMID: 26041393 DOI: 10.5692/clinicalneurol.cn-000676] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The present report describes a 54-year-old woman with cavernous sinus thrombosis (CST) presenting with fever, and marked periorbital swelling. There is a history of untreated periodontal disease. On initial examination, periorbital pain associated with bilateral blephaloptosis, chemosis, and disturbed eye movement was present. The laboratory evaluation showed significant elevations in inflammatory and fibrinolytic markers. Diffusion-weighted MRI revealed high signal intensities in the bilateral superior ophthalmic veins (SOV). Contrast-enhanced computed tomography (CT) of the cranium showed an enlarged right SOV and a non-enhancing lesion within the right SOV and bilateral cavernous sinus, indicating cavernous sinus thrombosis with diffuse SOV thrombosis. Blood culture performed on admission showed bacterial infection by intraoral resident flora; therefore, the CST was attributed to untreated periodontal disease. Contrast-enhanced CT of the case also revealed the presence of thrombosis in the jugular vein associated with micropulmonary embolus, indicating co-occurrence of Lemierre's syndrome. Antibiotic and anticoagulant treatment were initiated, and the tooth decay was treated; all clinical symptoms and signs subsequently improved. Additional neuroimaging showed that the thrombus was absent from both SOV and the cavernous sinus. Infectious CST is life threatening; therefore, laboratory and imaging examination should be performed quickly, and antibiotic and anticoagulant therapy administrated immediately.
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Affiliation(s)
- Akihiro Nishida
- Department of Neurology, Faculty of Medicine, Fukuoka University
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