Lemierre's Syndrome

; , Department of Surgery, Mount Sinai Medical Center, New York, NY (Anu Singhal is a 3rd-year medical student at Mount Sinai Medical School.)

South Med J. 2001;94(9) 

In This Article

Discussion

Lemierre's syndrome generally occurs in healthy adolescents and young adults.[2,3] The infection usually begins with a sore throat, followed by fever, septicemia, thrombosis, and metastatic abscesses. Purulent thrombophlebitis of the internal jugular vein can lead to pulmonary and other distant emboli. Septic arthritis can lead to osteomyelitis.

Fusobacterium necrophorum is a nonmotile, sporulating gram-negative anaerobe occurring in the normal flora of the pharynx, gastrointestinal tract, and female genital tract. It can become pathogenic, probably because of its toxins.[4] These bacteria produce a lipopolysaccharide endotoxin with strong biologic activity, as well as a leukocidin and hemolysin, assisting in destruction of white and red blood cells.[2,4] Hemagglutinin production augments the fulminant nature of the disease, causing platelet aggregation and septic thrombus formation.[2]

When pharyngitis due to F necrophorum occurs, the physical proximity of the vessels in the lateral pharyngeal space permits extension from the peritonsillar space to the internal jugular vein. This usually occurs in less than a week from the development of pharyngitis. Once internal jugular vein septic thrombosis occurs, distant dissemination is common.

The first sign of Lemierre's syndrome is usually a persistent fever, followed by acute pharyngitis and then sepsis. Next, neck tenderness or swelling develops. Contrast computed tomography of the neck provides the definitive diagnosis, showing distended veins with enhancing walls, intraluminal filling defects, and swelling of adjacent soft tissues.[1,2,4] Ultrasonography can also confirm internal jugular vein thrombosis, showing localized echogenic regions within a dilated vessel.[4,5] Confirmation of Lemierre's syndrome is provided by demonstration of F necrophorum on blood culture.[2]

Treatment of Lemierre's syndrome is high-dose parenteral antibiotics directed against anaerobes (clindamycin, metronidazole, chloramphenicol, imipenem, or cefodizime).[2] Prolonged therapy is recommended because of the endovascular nature of the infection.[2,3,4,5] Ligation or excision of the internal jugular vein is frequently required, and drainage of other abscesses may be necessary.[5]

Although rare, Lemierre's syndrome is potentially fatal. Early diagnosis and treatment are usually curative.

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