Lemierre’s syndrome

Rare, severe complication of oropharyngeal infection.

Known as necrobacillosis or anaerobic postanginal sepsis.

Most commonly affects young people with a median age of 22 years.

Incidence rate 3.6 cases per million.

Diagnosis associated with severe consequences including fatalities.

Use of antibiotics has decreased fatalities significantly.

Presently mortality is less than 2% with treatment.

Disease starts from acute pharyngitis than locally invades lateral pharyngeal space causing septic thrombophlebitis of the internal jugular vein and the subsequent development of distant metastatic septic emboli.

87% of cases start as acute pharyngitis.

The syndrome is characterized by 4-7 days of worsening pharyngitis and it’s a consideration in patients with persistent fever and pain on one side of the neck.
A palpable neck cord can indicate thrombosis of the internal jugular vein, but it is not a sensitive nor specific finding.
Infection of the pharynx and tonsils are the most common source of LS occurring in 67% of patients, with infection of the lung occurring in 25%, larynx, ears, mastoid process, sinuses, teeth, and eyes being less common.

Thrombophlebitis of the internal jugular vein is associated more than 70% of cases.

90% of patients develop metastatic septic emboli.

Bacteria believed to track along vascular planes, eventually invading the carotid sheath with subsequent inflammation thought to trigger a local hypercoagulable process, promoting thrombosis.

Most common pathogen is F necrophorum an anaerobic gram-negative bacilli found in normal oropharyngeal flora.

F necrophorum  is a member of the oral microbiome in 10-48% of patients age 15-45 years old and is responsible for 30-58% of published cases of LS.

Late manifestations include distant metastatic lesions, most commonly to lungs, and joints.

Complications of LS include sepsis, thromboembolism, pharyngitis, and  CNS infection.

Other sites of metastases include bones, liver, meninges, kidneys, skin and soft tissues.

Laboratory findings include leukocytosis, elevated C reactive protein, thrombocytopenia in 50% of cases and abnormal liver functions.

Differential diagnosis includes viral pharyngitis, mononucleosis, leptospirosis, pneumonia, endocarditis, and intra-abdominal sepsis.

Commonly diagnosed in a delayed fashion.

CXR may demonstrate infiltrates, cavities, and pleural effusion.

CT of neck can diagnosis of internal jugular vein thrombophlebitis, as can MRI or ultrasound.

Associated with positive F necrophorum blood culture in almost 70% of cases.

F necrophorum, hey Graham negative bacilli where are resistant to vancomycin but susceptible to Cabopenems and piperacillin-tazobactam.

Treatment beta-lactate resistant antibiotics with anaerobic coverage 2-6 weeks.

Surgical drainage may be efficacious.

Use of anticoagulation is debate able.

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