Lemierre’s Syndrome

15 Oct

What is it?  Lemierre’s Syndrome also known as postanginal septicemia refers to thrombophlebitis of the internal jugular vein.  See figure 1 below.

lem1

Figure 1:  Red arrow indicating infected thrombus of internal jugular vein.

 

Signs and Symptoms:  Lemierre’s Syndrome usually develops as a complication of a bacterial pharyngitis in young, healthy adults. Patients usually start with a sore throat, fever, and general body weakness. These are followed by swollen cervical lymph nodes, a tender or painful neck, with continued fevers. Sepsis and even septic shock can ensue. Karkos et. al did systematic review in 2009 looking at 84 studies/114 patients who had Lemierre’s syndrome . Table 1 shows the sources of infections.

lem2

Pathophysiology: Lemierre’s syndrome occurs most often when a bacterial throat infection, usually Fusobacterium necrophorum) progresses to the formation of a peritonsillar abscess. When the abscess wall ruptures internally, the drainage carrying bacteria seeps through the soft tissue and infects the nearby structures. Spread of infection to the nearby jugular vein leads to  inflammation surrounding the vein and compression of the vein may lead to clot formation.

 

Why is it so dangerous?  The infected thrombus of the internal jugular vein is a perfect gateway for the spread of bacteria through the bloodstream. Besides causing sepsis and septic shock, pieces of the infected clot break off leading to septic emboli of the pulmonary vasculature, where abscesses, nodules, cavitary lesions and pleural effusions develop.  Emboli can also affect the joints, muscles and soft tissues, liver, spleen, kidneys and brain.

 

Treatment:  Fusobacterium necrophorum is generally highly susceptible to beta-lactams, metronidazole, clindamycin and third generation cephalosporins. Additionally, a co-infection by another bacterium may co-exist. For these reasons is often advised not to use monotherapy in treating Lemierre’s syndrome.  The role of anticoagulation in treating Lemierre’s syndrome remains controversial.  Karkos et al. showed overall mortality to be 5%.

 

Submitted by Joran Sequeira, M.D.

 

References

  • Karkos et al. Lemierre’s Syndrome: a systematic review. August 2009. Laryngoscope, 119 (8): 1552-1559.
  • Syed et al. Lemierre syndrome: two cases and a review. September 2007. The Laryngoscope(The American Laryngological, Rhinological & Otological Society; Lippincott Williams & Wilkins). 117 (9): 1605–1610

 

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