Lemierre's syndrome
Background
- Also known as "Lemierre's disease" and "postanginal shock including sepsis" and "human necrobacillosis"
- Is a form of thrombophlebitis[1]
- Usually caused by Fusobacterium necrophorum, and occasionally by other members of the genus Fusobacterium (F. nucleatum, F. mortiferum and F. varium etc.) or MRSA
- Usually affects young, healthy adults, most often developing after Strep Pharyngitis causing peritonsilar abscess
- Anerobic Bacteria grow in the peritonsilar abscess and penetrate into the neighboring jugular vein causing thrombophlebitis and bacteremia and septic emboli and occassionally pneumonia and sepsis
Clinical Features
- Persistent sore throat, fever, and general weakness
- 2 days - 2 weeks after initial symptoms:
- Lethargy, fevers, lymphadenopathy, painful neck
- Often abdominal pain, diarrhea, nausea and vomiting
- May lead to:
- Pneumonia
- Septic Arthritis
- Meningitis
- Sepsis
- Intracranial complications (6%)
Differential Diagnosis
- Q fever
- Tuberculosis
- Pneumonia
- Viral pharyngitis
- Mononucleosis-like illnesses (EBV, CMV, acute HIV)
- Peritonsillar abscess vs. Retropharyngeal abscess vs. Ludwig's angina
- Mumps
- Sjögren Syndrome
- Heerfordt's syndrome (small percentage of sarcoidosis)
Bacterial infections
- Streptococcal pharyngitis (Strep Throat)
- Neisseria gonorrhoeae
- Diphtheria (C. diptheriae)
- Bacterial Tracheitis
Viral infections
- Infectious mononucleosis (EBV)
- Patients with peritonsillar abscess have a 20% incidence of mononucleosis [4]
- Laryngitis
- Acute Bronchitis
- Rhinovirus
- Coronavirus
- Adenovirus
- Herpesvirus
- Influenza virus
- Coxsackie virus
- HIV (Acute Retroviral Syndrome)
Other
- Deep neck space infection
- Peritonsillar Abscess (PTA)
- Epiglottitis
- Kawasaki disease
- Penetrating injury
- Caustic ingestion
- Lemierre's syndrome
- Peritonsillar cellulitis
- Lymphoma
- Internal carotid artery aneurysm
- Oral Thrush
- Parotitis
- Post-tonsillectomy hemorrhage
- Vincent's angina
- Acute necrotizing ulcerative gingivitis
Evaluation
Workup
POCUS shows IJ thrombus[5]
- CTA of neck
- Point of care ultrasound may reveal IJ thrombus
- Blood Cultures
Evaluation
Diagnostic criteria:
- History of oropharynx pain within last 4 wks
- Evidence of IJV thrombophlebitis/carotid sheath
- Isolation of F. necrophorum from blood
- Evidence of metastatic infection in another site (lungs)
Management
- Antibiotics (coverage of F. necrophorum, strep, bacteroides) - Unasyn, Zosyn, or carbapenem for at least 3-4 wks
- IV Antibiotics
- Drainage of abscess
- Consider ligation of the internal jugular vein where antibiotic can not penetrate.[6]
- No evidence for or against anticoagulation[7]
Disposition
- Admit
See Also
Video
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References
- "Lemierre syndrome" at Dorland's Medical Dictionary
- Sibai K, Sarasin F (2004). "Lemierre syndrome: a diagnosis to keep in mind". Revue médicale de la Suisse romande (in French) 124 (11): 693–5. PMID 15631168.
- Centor RM. "Expand the Pharyngitis Paradigm for Adolescents and Young Adults." Ann Intern Med. 2009;151(11):812-815. doi:10.7326/0003-4819-151-11-200912010-00011
- Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
- http://www.thepocusatlas.com/soft-tissue-vascular/
- Chirinos JA, Lichtstein DM, Garcia J, Tamariz LJ (November 2002). "The evolution of Lemierre syndrome: report of 2 cases and review of the literature". Medicine (Baltimore) (Lippincott Williams & Wilkins) 81 (6): 458–465. doi:10.1097/00005792-200211000-00006. PMID 12441902.
- Puymirat E, Biais M, Camou F, Lefèvre J, Guisset O, Gabinski C (March 2008). "A Lemierre's syndrome variant caused by Staphylococcus aureus". American journal of emergency medicine test (Elsevier) 26 (3): 380–387. doi:10.1016/j.ajem.2007.05.020. PMID 18358967.
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