Epidemiology
History
- Lemierre’s Syndrome was First Described in a Case Series (20 Patients) by Lemierre in 1936: 18 patients in the series died
- Mortality was >50% in the Pre-Antibiotic Era (Prior to the 1950’s)
- Lemierre’s Syndrome Became Far Less Prevalent in the 1950’s-1960’s
- Recent Resurgence of Reporting of Lemierre’s Syndrome Cases in the 1990’s-2000’s: unclear if this reflects a true increase in disease incidence
Demographics
- Mean Age: 22 y/o (Laryngoscope, 2009) [MEDLINE]
- Male:Female Ratio: 1:1 (Laryngoscope, 2009) [MEDLINE]
Microbiology
- Fusobacterium Species (see Fusobacterium, [[Fusobacterium]])
- Anaerobic Gram-Negative Rods, Which are Typically a Non-Pathogenic Organism in the Oral Flora
- Fusobacterium is Often Mistaken for Bacteroides Species
- Fusobacterium is the Most virulent and Common Etiologic Pathogen in Lemierre’s Syndrome *
- Species
- Fusobacterium Nucleatum
- Fusobacterium Necrophorum: most common organism (Laryngoscope, 2009) [MEDLINE]
- Bacteroides Species (see Bacteroides, [[Bacteroides]])
- Peptostreptococcus Species (see Peptostreptococcus, [[Peptostreptococcus]])
- Eikenella Corrodens (see Eikenella Corrodens, [[Eikenella Corrodens]])
- Streptococcus Pyogenes (see Streptococcus Pyogenes, [[Streptococcus Pyogenes]]): rare etiology
- Salmonella (see Salmonella, [[Salmonella]]): rare etiology
Physiology
Jugular Vein Suppurative Thrombophlebitis
- Source of Infection (Laryngoscope, 2009) [MEDLINE]
- Tonsil: 37 % of cases
- Lemierre’s Syndrome Occurs 4-5 days After Onset of the Tonsillitis Episode
- Pharynx (Upper Respiratory Tract) (see Pharyngitis, [[Pharyngitis]]): 30% of cases
- Lemierre’s Syndrome Occurs 4-5 days After Onset of the Pharyngitis Episode
- Chest (Lower Respiratory Tract): 25% of cases
- Middle Ear/Mastoid: 2% of cases
- Larynx: 2% of cases
- Dental Infection (see Dental Abscess, [[Dental Abscess]]): 1% of cases
- Paranasal Sinuses (see Acute Rhinosinusitis, [[Acute Rhinosinusitis]]): 1% of cases
- Orbit: 1% of cases
- Metastatic Disease: 0.5% of cases
- Gastrointestinal: 0.4% of cases
- Lip Piercing: 0.1% of cases
- Infectious Mononucleosis (see Infectious Mononucleosis, [[Infectious Mononucleosis]])
- Septic Embolism with Metastatic Abscesses
- Lung
- Pleura
- Bone
- Liver
- Spleen
- Retrograde Extension to Cavernous Sinus
- May Result in Cavernous Sinus Thrombosis or Meningitis
Diagnosis
Chest X-Ray (see Chest X-Ray, [[Chest X-Ray]])
- Findings
- Pleural Effusion (see xxxx, [[xxxx]])
- Septic Embolic Infiltrates (see Lung Nodule or Mass, [[Lung Nodule or Mass]])
- Findings
- Pleural Effusion (see xxxx, [[xxxx]])
- Septic Embolic Infiltrates (see Lung Nodule or Mass, [[Lung Nodule or Mass]])
Neck CT with Intravenous Contrast (see Neck Computed Tomography, [[Neck Computed Tomography]])
- Diagnostic
- Findings
- Internal Jugular Vein Thrombosis
Blood Culture (see Blood Culture, [[Blood Culture]])
- May Take 2-7 Days for Fusobacterium Necrophorum to Grow
Clinical Manifestations
Cardiovascular Manifestations
- Tamponade (see Tamponade, [[Tamponade]])
- Epidemiology: 7% of cases (Laryngoscope, 2009) [MEDLINE]
Gastrointestinal Manifestations
- Hepatic Infarct (see xxxx, [[xxxx]])
- Epidemiology: overall, hepatic manifestations (including infarct and abscess) occur in 6% of cases (Laryngoscope, 2009) [MEDLINE]
- Jaundice/Elevated LFT’s (see Elevated Liver Function Tests, [[Elevated Liver Function Tests]])
- Epidemiology: LFT’s are abnormal in 50% of cases
- Pyogenic Liver Abscess (see xxxx, [[xxxx]])
- Epidemiology: overall, hepatic manifestations (including infarct and abscess) occur in 6% of cases (Laryngoscope, 2009) [MEDLINE]
- Other Gastrointestinal Symptoms
- Epidemiology: 1% of cases (Laryngoscope, 2009) [MEDLINE]
Hematologic Manifestations
- Splenic Infarct (see xxxx, [[xxxx]])
- Epidemiology: overall, splenic manifestations (including infarct and abscess) occur in 6% of cases (Laryngoscope, 2009) [MEDLINE]
Neurologic Manifestations
- Brain Abscess (see Brain Abscess, [[Brain Abscess]])
- Epidemiology: overall, brain manifestations (including brain abscess, meningitis, epidural/subdural abscess, cavernous/sigmoid/transverse/lateral sinus thrombosis, and stroke) occur in 30% of cases (Laryngoscope, 2009) [MEDLINE]
- Cavernous/Sigmoid/Transverse/Lateral Sinus Thrombosis (see Cerebral Venous Thrombosis, [[Cerebral Venous Thrombosis]])
- Epidemiology: overall, brain manifestations (including brain abscess, meningitis, epidural/subdural abscess, cavernous/sigmoid/transverse/lateral sinus thrombosis, and stroke) occur in 30% of cases (Laryngoscope, 2009) [MEDLINE]
- Epidural/Subdural Abscess (see Intracranial Epidural Abscess, [[Intracranial Epidural Abscess]] and Intracranial Subdural Abscess, [[Intracranial Subdural Abscess]])
- Epidemiology: overall, brain manifestations (including brain abscess, meningitis, epidural/subdural abscess, cavernous/sigmoid/transverse/lateral sinus thrombosis, and stroke) occur in 30% of cases (Laryngoscope, 2009) [MEDLINE]
- Ischemic Cerebrovascular Accident (CVA) (see Ischemic Cerebrovascular Accident, [[Ischemic Cerebrovascular Accident]])
- Epidemiology: overall, brain manifestations (including brain abscess, meningitis, epidural/subdural abscess, cavernous/sigmoid/transverse/lateral sinus thrombosis, and stroke) occur in 30% of cases (Laryngoscope, 2009) [MEDLINE]
- Cranial Nerve 11 and 12 Palsies
- Epidemiology: 3% of cases (Laryngoscope, 2009) [MEDLINE]
- Meningitis (see Meningitis, [[Meningitis]]): may occur in cases with retrograde extension to cavernous sinus
- Epidemiology: overall, brain manifestations (including brain abscess, meningitis, epidural/subdural abscess, cavernous/sigmoid/transverse/lateral sinus thrombosis, and stroke) occur in 30% of cases (Laryngoscope, 2009) [MEDLINE]
Ophthalmologic Manifestations
- Uveitis (see Uveitis, [[Uveitis]])
- Epidemiology: overall, ophthalmologic manifestations (including uveitis, vitreous hemorrhage, retrobulbar mass, and cranial nerve 6 palsy) occur in 5% of cases (Laryngoscope, 2009) [MEDLINE]
- Vitreous Hemorrhage
- Epidemiology: overall, ophthalmologic manifestations (including uveitis, vitreous hemorrhage, retrobulbar mass, and cranial nerve 6 palsy) occur in 5% of cases (Laryngoscope, 2009) [MEDLINE]
Otolaryngologic Manifestations
- Deep Neck Infection (see Deep Neck Infection, [[Deep Neck Infection]])
- Epidemiology: 14% of cases (Laryngoscope, 2009) [MEDLINE]
- Clinical: parapharyngeal or retropharyngeal abscess
- Dental Pain (see Dental Pain, [[Dental Pain]])
- Epidemiology: 5% of cases (Laryngoscope, 2009) [MEDLINE]
- Internal Jugular Vein Thrombosis (see Internal Jugular Vein Thrombosis, [[Internal Jugular Vein Thrombosis]])
- Mastoiditis (see Mastoiditis, [[Mastoiditis]])
- Epidemiology: 6% of cases (Laryngoscope, 2009) [MEDLINE]
- Neck Mass (see Neck Mass, [[Neck Mass]])
- Epidemiology: 23% of cases (Laryngoscope, 2009) [MEDLINE]
- Neck Pain (see Neck Pain, [[Neck Pain]])
- Epidemiology: 20% of cases (Laryngoscope, 2009) [MEDLINE]
- Otalgia/Otorrhea (see Otalgia, [[Otalgia]] and Otorrhea, [[Otorrhea]])
- Epidemiology: 8% of cases (Laryngoscope, 2009) [MEDLINE]
- Orbital Pain (see Eye Pain, [[Eye Pain]])
- Epidemiology: 1% of cases (Laryngoscope, 2009) [MEDLINE]
- Pharyngitis (see Pharyngitis, [[Pharyngitis]])
- Epidemiology: 33% of cases (Laryngoscope, 2009) [MEDLINE]
- Clinical: exam may be normal or may demonstrate ulcers or pseudomembrane
- Rhinorrhea (see Rhinorrhea, [[Rhinorrhea]])
Pulmonary Manifestation
- General Comments
- Over 90% of Cases have Pleuropulmonary Involvement
- Mediastinitis (see Mediastinitis, [[Mediastinitis]])
- Epidemiology: overall, pulmonary manifestations (including mediastinitis, empyema, pleural effusion, pneumothorax, and pneumonia) occur in 22% of cases (Laryngoscope, 2009) [MEDLINE]
- Pleural Effusion/Empyema (see Pleural Effusion-Exudate, [[Pleural Effusion-Exudate]] and xxxx, [[xxxx]])
- Epidemiology: overall, pulmonary manifestations (including mediastinitis, empyema, pleural effusion, pneumothorax, and pneumonia) occur in 22% of cases (Laryngoscope, 2009) [MEDLINE]
- Pleuritic Chest Pain (see Chest Pain, [[Chest Pain]])
- Septic Emboli to Lungs (see Septic Embolism, [[Septic Embolism]])
- Epidemiology: overall, pulmonary manifestations (including mediastinitis, empyema, pleural effusion, pneumothorax, and pneumonia) occur in 22% of cases (Laryngoscope, 2009) [MEDLINE]
- Clinical
- Cough (see Cough, [[Cough]])
Renal Manifestations
Rheumatologic Manifestations
- Myalgias (see Myalgias, [[Myalgias]])
- Osteomyelitis (see Osteomyelitis, [[Osteomyelitis]])
- Clinical: involving the humerus, hip, clavicle, tibia, and fibula
- Septic Arthritis (see Septic Arthritis, [[Septic Arthritis]])
- Clinical: involving the humerus, hip, clavicle, tibia, and fibula
- Bone/Joint Pain: 8% of cases (Laryngoscope, 2009) [MEDLINE]
- Soft Tissue Abscesses (see xxxx, [[xxxx]])
Other Manifestations
- Fever (see Fever, [[Fever]])
- Sepsis (see Sepsis, [[Sepsis]])
Treatment
Antibiotics
Agents
- β-Lactamase Resistant β-Lactam
- Vancomycin (see xxxx, [[xxxx]]): may be added to cover skin flora for cases with catheter associated jugular vein suppurative thrombophlebitis
- Other Agents
- Ineffective Agents
- Gentamicin (see Gentamicin, [[Gentamicin]])
- Macrolides (see Macrolides, [[Macrolides]])
- Penicillin (see Penicillins, [[Penicillins]]): failure with penicillin has been reported (and β-lactamase producing Fusobacterium Necrophorum has been reported)
Duration of Therapy
- Treatment Duration Should Be at Least 4 wks (with a Minimum of 2 wks of Intravenous Therapy) and Extend Until Pulmonary Abscesses Resolve by CT Scan
Drainage of Oropharyngeal Abscesses
Anticoagulation
- Anticoagulation Has Unclear Clinical Efficacy in Lemierre’s Syndrome with Internal Jugular Vein Thrombosis, But Without Cavernous Sinus Thrombosis
- Some Authors Suggest Anticoagulation Only When There is Extension of Thrombus (Postgrad Med J, 1999) [MEDLINE]
- Indications
Internal Jugular Vein Ligation
Prognosis
- Mortality Rate: 5% (Laryngoscope, 2009) [MEDLINE]
References
- Lemierre A. On certain septicemias due to anaerobic organisms. Lancet. 1936;1:701-3
- The Lemierre syndrome: suppurative thrombophlebitis of the internal jugular vein secondary to oropharyngeal infection. Medicine 1989; 69:85-94
- Lemierre’s syndrome (necrobacillosis). Postgrad Med J. 1999;75(881):141 [MEDLINE]
- Human necrobacillosis, with emphasis on Lemierre’s syndrome. Clin Infect Dis. 2000 Aug;31(2):524-32. Epub 2000 Sep 14 [MEDLINE]
- The evolution of Lemierre syndrome: report of 2 cases and review of the literature. Medicine (Baltimore). 2002 Nov;81(6):458-65 [MEDLINE]
- Lemierre’s syndrome: A systematic review. Laryngoscope. 2009 Aug;119(8):1552-9. doi: 10.1002/lary.20542 [MEDLINE]