Lemierre's syndrome

Background

• Also known as "Lemierre's disease" and "postanginal shock including sepsis" and "human necrobacillosis"
• Is a form of thrombophlebitis
• 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

Epidemiology

• Very rare, incidence rate of 0.8 cases per million in the general population
• When diagnosed, mortality is 4.6%

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%)
• Diagnostic criteria
  • Hx 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)

Differential Diagnosis

• Q fever
• Tuberculosis
• Pneumonia
• Viral pharyngitis
• Mononucleosis-like illnesses (EBV, CMV, acute HIV)
• PTA vs. RA vs. Ludwig's
• Mumps
• Sjogren's
• Heerfordt's syndrome (small percentage of sarcoidosis)

Workup

• CTA of neck
• Blood Cultures

Management

• Antibiotics (coverage of F. necrophorum, strep, bacteroides) - Unasyn, Zosyn, or carbapenam for at least 3-4 wks
  • IV Antibiotics
• Drainage of abscess
• Consider ligation of the internal jugular vein where antibiotic can not penetrate.
• No evidence for or against anticoagulation

Disposition

• Admit

See Also

• Peritonsilar abscess
• Sepsis