Lemierre Syndrome


Article Author:
Brady Allen


Article Editor:
Thomas Bentley


Editors In Chief:
Venkat Minnaganti
John Brusch
Janak Koirala


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
5/14/2019 3:36:42 PM

Introduction

Lemierre syndrome (LS) is named after the French physician, Andre Lemierre, who in 1936 reported 20 cases of anaerobic septicemia originating from oropharyngeal infections. It is a rare complication of bacterial pharyngitis/tonsillitis and involves an extension of the infection into the lateral pharyngeal spaces of the neck with subsequent septic thrombophlebitis of the internal jugular vein(s). It is associated with anaerobic septicemia and death in young, healthy patients. Due to the high frequency of benign oropharyngeal infections in this population, the diagnosis of LS is often elusive on initial presentation. This can result in treatment delays.[1][2][3]

Etiology

Lemierre syndrome originates as a complication of bacterial throat infections. The bacteria most commonly responsible is Fusobacterium necrophorum, an obligate anaerobic, gram-negative bacilli. F. necrophorum and Fusobacterium nucleatum are the responsible for the majority of human fusobacterial infections. These bacteria can cause invasive disease secondary to multiple virulence factors including endotoxins and exotoxins. Other organisms such as Streptococcus species., Bacteroides species., Staphylococcus aureus, Klebsiella pneumoniae, and others have also been isolated in reported case studies.[4][5][6]

F. necrophorum is part of the normal bacterial flora in the pharynx, gastrointestinal tract, and female genital tract. In addition to primary infection, it is postulated that other etiologies of oropharyngeal infections can lead to conditions that are conducive to fusobacterial growth. These may be viral infections such as acute Epstein Barr, streptococcal infections, and others. Conditions conducive to anaerobic growth, like a peritonsillar abscess, allow growth and penetration of the surrounding tissues by F. necrophorum.  Extension of the infection from the oropharynx into the lateral pharyngeal space results in the seeding of the internal jugular vein, septic thrombophlebitis, and subsequent access to the venous system resulting in septicemia and septic emboli.[7][8]

Epidemiology

The highest reported incidence of Lemierre syndrome was prior to the antibiotic era. With the widespread use of penicillin in the 1960s and 1970s, the incidence of LS declined sharply. Since the late 1970s, there has been a steady rise in reported cases which may be due to the decreased use of empiric antibiotics in oropharyngeal infections. It is still a rare syndrome with an estimated worldwide incidence of 1/1,000,000. LS typically affects young, previously healthy, adolescents and young adults. The median age of patients with LS is between 19 to 22 years of age depending on the study with a 2:1 male-to-female ratio. Approximately 90% of the patients who develop LS are between 10 and 35 years of age.

Pathophysiology

Liemierre syndrome begins as a localized oropharyngeal infection. It is not known definitively whether F. necrophorum acts predominantly as a primary or secondary pathogen in the initial stages of LS. In addition to direct infection, it is postulated that mucosal damage of the pharynx caused by other bacterial or viral infections leads to conditions conducive for a fusobacterial superinfection. The infection then spreads into the lateral pharyngeal space and soft tissues of the neck. Venous thrombosis is initiated locally in the peritonsillar veins and then extends to the internal jugular veins. F. necrophorum has been shown to aggregate human platelets in vitro, subsequently precipitating intravascular coagulation. When combined with venous stasis from extrinsic compression and intrinsic vessel occlusion secondary to inflammation and edema, this leads to the development of septic thrombosis of the internal jugular vein. The release of septic emboli into the systemic circulation results in widespread dissemination of F. necrophorum into the lung, pleura, joints, bones, muscles, spleen, liver, kidney, and other endpoints of circulation. Direct extension or propagation of thrombus results in central nervous system abscess formation as well as cavernous sinus thrombosis.

History and Physical

The presentation and clinical progression of Lemierre disease can usually be divided into 3 main phases. These phases may also serve to diagnose the syndrome.

Oropharyngeal infection

The clinical features of Lemierre syndrome begin with an oropharyngeal infection with subsequent febrile episodes and rigors anywhere from 4 to 7 days after the initial illness. Early diagnosis can be challenging as the symptoms are non-specific and usually attributable to self-limited pharyngeal infections. Over two-thirds of patients recount a pharyngeal infection at the onset of the illness, but rarely the illness has been described in the setting of parotitis, otitis media, mastoiditis, sinusitis, and dental infections. Patients with confirmed Epstein-Barr infections may also develop LS, and seropositive patients with mononucleosis can suffer diagnostic delays when LS is not considered as an alternative diagnosis. The persistence of fever and worsening clinical status at 1 week can be an important clinical clue.

Infection Extension to the Paraphernal Space of the Neck with Thrombophlebitis of the Internal Jugular Vein

Neck tenderness and swelling may be an early clinical sign that pharyngitis has extended beyond the oropharynx. Unilateral tenderness and swelling at the mandibular angle, known as the “cord sign,” indicates internal jugular thrombosis, but is only present in 25% to 45% of cases. A focused exam of the neck including the suprasternal and supraclavicular regions for signs of cutaneous cellulitis should also be performed and can indicate an extension of the infection to cervical veins and the mediastinal structures.

Septic Emboli

Once F. necrophorum has invaded the cervical veins, septic emboli occur. The most frequently affected organ is the lungs (85%), but joints, liver, kidney, brain, bones, heart and meninges can all be involved. Bacteremia is associated with fever, lethargy, or shock, as well as end-organ damage. Septic shock occurs in approximately 7% of cases. Acute respiratory distress syndrome requiring mechanical ventilation may affect up to 10% of patient presentations.

Evaluation

The diagnosis of Lemierre syndrome is primarily clinical, but adjunctive testing can be helpful. Comprehensive laboratory evaluation is indicated in patients presenting with concern for sepsis or with systemic inflammatory response syndrome (SIRS) criteria. Some of the more frequent laboratory abnormalities include leukocytosis, mild to severe renal impairment, abnormal liver function tests including elevated bilirubin, thrombocytopenia, as well as other evidence of disseminated intravascular coagulation. Blood cultures should be collected, and growth typically occurs over 2 to 7 days and shows Fusobacterium species in over 70% of cases. Blood cultures may be negative in LS due to the difficulties that can be associated with culturing anaerobic organisms.

The lungs are the most common site of metastatic infection, and imaging should include a chest radiograph to evaluate for septic emboli and other pulmonary complications including pulmonary effusions, pulmonary abscess, and empyema. Additional sites of bacterial metastasis result may result in septic arthritis, osteomyelitis, meningitis, pericarditis, and hepatic abscess. Other imaging modalities used to evaluate for septic thrombosis of the internal jugular vein may include ultrasound, CT of the neck with contrast, and magnetic resonance imaging (MRI). MRV has the highest sensitivity (97%) for detecting internal jugular thrombosis, while CT is usually the most available and most widely used clinically. Ultrasound can be a useful modality given its comparatively lower cost and lack of radiation risk, but the low echogenicity of fresh clots combined with anatomic constraints of the lower neck result in lower sensitivity for the detection of acute thrombosis.

Treatment / Management

The mainstay of treatment for Lemierre syndrome is antibiotic therapy. A beta-lactamase resistant beta-lactam antibiotic is recommended as an empiric therapy due to case reports of treatment failures with penicillin secondary to beta-lactamase producing F. necrophorum. Antibiotics should be tailored to the culture results and susceptibility data when available. Alternative options include clindamycin or metronidazole for patients with significant clinical allergy to beta-lactams. Antibiotic therapy is continued for 6 weeks in most patients to achieve appropriate penetration into fibrin clots.

Surgical management may be necessary in cases of abscess formation, respiratory distress secondary to pulmonary thrombosis metastasis, and in patients with extension of thrombus into the mediastinum or cerebrum. Surgical incision and drainage of the abscess at affected sites may be indicated to control infection.

Anticoagulation therapy in Lemierre syndrome is controversial. Uncomplicated LS without evidence of extensive clot burden resolves with appropriate antibiotic therapy and supportive care and does not require anticoagulation. There are no controlled trials to validate the practice, but anticoagulation is usually recommended when thrombus extends into the cerebral sinuses, for large or bilateral clot burden, or when a patient fails to improve in the first 72 hours with appropriate antibiotic and/or surgical therapy.

Differential Diagnosis

The differential diagnosis for early LS is broad and consists of all causes of oropharyngeal infections both viral and bacterial. Advanced LS can mimic any cause of systemic bacteremia with or without septic emboli.

Prognosis

Advanced Lemierre syndrome is a life-threatening condition. Even with appropriate antibiotics and therapy, mortality has been reported to be between 5% and 18%. Hospital admission usually requires intensive care unit (ICU) status, and the average length of stay in the hospital is approximately 3 weeks. Septic emboli and end-organ effects can result in long-term morbidity.

Pearls and Other Issues

The diagnosis of Lemierre syndrome should be considered in young, otherwise healthy patients with an underlying oropharyngeal infection that present with a worsening clinical course and subsequent sepsis with evidence for metastatic septic emboli.

Enhancing Healthcare Team Outcomes

Lemierre syndrome is best managed by a multidisciplinary team that also includes nurse practitioners. When patients present with oral cavity infections, one should always consider the fact these oral bacteria can migrate to adjacent tissues including the jugular veins. From here the septic embolic can go to any part of the body including the lungs. The treatment of lemierre syndrome is antibiotics and the role of anticoagulation remains controversial. However, if there is a thrombus in the veins, then anticoagulation must be started.

The outlook for patients with this syndrome is guarded. Case reports reveal a high mortality despite optimal treatment.


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Lemierre Syndrome - Questions

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A 17-year-old male presents with a persistent sore throat despite being treated for strep throat 3 weeks prior to arrival. He notes no testing was done at that time. He has associated myalgias, diarrhea, and occasional nausea and vomiting. On exam, he appears in some discomfort with a fever of 102.2 F. His exam is significant for oropharyngeal erythema and edema with some right lateral neck tenderness and moderate swelling. A CT angiogram of the neck shows findings consistent with thrombophlebitis in the internal jugular vein. Which of the following is likely to grow from the patient's blood cultures?



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A 17-year-old previously healthy male presents to the emergency department for evaluation of 2 to 3 weeks of progressive throat pain. He was first evaluated 10 days before in his primary care provider's office. Strep and Mono testing at that time were negative. Vitals are notable for a pulse of 90 bpm, blood pressure 115/70 mmHg, respiratory rate of 15/minute, and oxygen saturation of 100% on room air. He is in no acute distress. Exam shows right lateral neck swelling. Workup includes laboratory testing, chest x-ray, and a CT angiogram of the neck. Results include a leukocytosis of 15,000 with a left shift, but normal hemoglobin, hematocrit, and platelet count. Chest x-ray is normal. CT angiogram shows thrombophlebitis of the right internal jugular vein without abscess formation. What is the next most important step in this patient's management?



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Which of the following statements regarding the use of anticoagulation in Lemierre syndrome is incorrect?



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A 17-year-old previously healthy female presents with fever and throat pain. She was diagnosed with a viral infection 2 weeks ago. Her condition has worsened, and she now complains of left lateral neck pain. What would be most suggestive of Lemierre syndrome?



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A 17-year-old female presents with a diagnosis of mononucleosis made three weeks ago by her provider. Her mother reports she has steadily worsened since that time despite corticosteroids and one additional visit for intravenous fluids. More recently, her daughter has developed a productive cough, and she has noticed some right lateral neck swelling. She has had near continuous fever, and also a persistent sore throat. Vital signs show a fever of 102 F, pulse 120 bpm, blood pressure of 115/70 mmHg, and 100% oxygen saturation on room air. Exam shows a sick but non-toxic appearing female with a "cord sign" present deep to the anterior border of the sternocleidomastoid on the right side. Also, she has palpable lymphadenopathy present bilaterally. What imaging study listed below is most sensitive for confirming the diagnosis?



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Lemierre Syndrome - References

References

Vincent B,Yannick H,Adrien M,Sandrine V,     [PubMed]
Walkty A,Embil J, Lemierre's Syndrome. The New England journal of medicine. 2019 Mar 21;     [PubMed]
Veras RO,Barasuol LL,de Lira CP,Klostermann FC,Müller LS,Nercolini LE,Nogueira GF, Lemierre syndrome: case report. Jornal vascular brasileiro. 2018 Oct-Dec;     [PubMed]
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. Journal of chemotherapy (Florence, Italy). 2019 Feb;     [PubMed]
Salami A,Assouan C,Garba I,Konan E, An unusual cause of Lemierre Syndrome. Journal of stomatology, oral and maxillofacial surgery. 2019 Feb 14;     [PubMed]
Yamamoto S,Okamoto K,Okugawa S,Moriya K, Fusobacterium necrophorum septic pelvic thrombophlebitis after intrauterine device insertion. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2019 Apr;     [PubMed]
Jafri FN,Shulman J,Gómez-Márquez JC,Lazarus M,Ginsburg DM, Sore Throat, Fever, Septic Emboli, and Acute Respiratory Distress Syndrome: A Case of Lemierre Syndrome. Case reports in emergency medicine. 2018;     [PubMed]
Le C,Gennaro D,Marshall D,Alaev O,Bryan A,Gelfman A,Wang Z, Lemierre's syndrome: One rare disease-Two case studies. Journal of clinical pharmacy and therapeutics. 2019 Feb;     [PubMed]

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