Lemierre syndrome

OVERVIEW

  • Lemierre syndrome is thrombophlebitis of the internal jugular (IJ) vein and bacteraemia caused by primarily anaerobic organisms, following a recent oropharyngeal infection
  • a ‘forgotten’ disease first described by Andre Lemierre in 1936, Lemierre syndrome has increased in incidence since the 1990s
  • mostly affects children, adolescents and young adults
  • delayed diagnosis is common

CAUSE

Infection due to:

  • fusobacterium species, especially fusobacterium necrophorum most commonly (an anaerobic GNB, a part of normal oral flora)
  • One third have a  polymicrobial bacteraemia (typically anaerobic streptococci and other miscellaneous gram-negative anaerobes)
  • other gram positive causes have been reported (e.g. S.aureus)

PATHOPHYSIOLOGY

Primary infection is followed by local invasion of the lateral pharyngeal space then septic thrombophlebitis of the IJ vein

  • primary source of infection is commonly the palatine tonsils and peritonsillar tissue
  • other sources include the lungs, middle ear, mastoid, teeth and sinuses
  • may follow on from a viral (e.g. EBV) or bacterial pharyngitis of another cause

Metastatic infections following the IJ thrombophlebitis occur in >2/3 of cases

  • lungs, joints, liver, muscle, pericardium, brain and skin

Complications

  • Thrombosis may propagate from the IJ vein inferiorly into the subclavian vein or superiorly into the cavernous, sigmoid or transverse sinuses
  • metastatic infection
  • DIC (~5%)
  • meningitis (3%)
  • septic shock
  • death (near 100% mortality in the pre-antibiotic era)

CLINICAL FEATURES

Clinical manifestations vary according to the presence of metastatic complications

  • Fever (but may appear otherwise well)
  • Pharyngitis/peritonsillar abscess
  • Anterior cervical lymphadenopathy
  • Neck mass/tenderness (~50%)
  • Trismus
  • Cranial nerve 10, 11, 12 palsies
  • Septic arthritis (most commonly hip or knee)
  • Jaundice/hepatomegaly
  • Shock

INVESTIGATIONS

Bedside

  • glucose +/- VBG

Laboratory

  • FBC, UEC, LFTs
  • Septic screen including blood cultures
  • Joint fluid aspirates if appropriate

Imaging

  • CXR — metastatic infection of the lungs is common: nodules, cavities, effusions
  • CT Neck with contrast — IJV thrombophlebitis and/or neck mass/ collections

MANAGEMENT

Resuscitation

  • address life threats such as airway compromise, respiratory failure and septic shock

Specific therapy

  • antibiotics
    • if severely unwell: piperacillin+tazobactam 4/0.5 g (child: 100+12.5 mg/kg up to 4/0.5 g) IV q8h
    • if systemically unwell: benzylpenicillin 1.2 g (child: 50 mg/kg up to 1.2 g) IV q6h AND metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) IV q12h
    • if systemically well: amoxicillin/ clavulanate or clindamycin
    • typically 2-6 weeks duration
  • anticoagulation
    • controversial (administered in about 1/4 to 1/3 of case reports)
    • some recommend if IJ thrombophlebitis leads to venous sinus thrombosis or failure to improve with antibiotics

Supportive care and monitoring


References and Links

LITFL

Journal articles

  • Eilbert W, Singla N. Lemierre’s syndrome. Int J Emerg Med. 2013 Oct 23;6(1):40. doi: 10.1186/1865-1380-6-40. PubMed PMID: 24152679; PubMed Central PMCID: PMC4015694.
  • Riordan T. Human infection with Fusobacterium necrophorum (Necrobacillosis), with a focus on Lemierre’s syndrome. Clin Microbiol Rev. 2007 Oct;20(4):622-59. Review. PubMed PMID: 17934077; PubMed Central PMCID: PMC2176048.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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