Article, Infectious Diseases

Lemierre syndrome: no delays in management

Case Report

Lemierre syndrome: no delays in management Abstract

Lemierre syndrome is characterized by a history of recent oropharyngeal infection, clinical or radiologic evidence of internal jugular vein thrombosis, and isolation of anaerobic pathogens, mainly fusobacterium necro- phorum. There has been an increase in reporting of Lemierre syndrome over the last 10 years. Whether this reflects a true increase in the incidence of this previously rare disease or just a literature/publishing trend, it remains to be seen. We present a case of a healthy teenager who was managed successfully, thanks to immediate multidisciplin- ary approach and high index of suspicion.

A 17-year-old boy was referred to the Ear Nose and Throat clinic from the Accident and Emergency Department with a level II-III unilateral neck swelling of 1-week duration. He was initially seen by his general practitioner and was wrongly diagnosed with mumps. On examination, he had an obvious neck abscess (Fig. 1), rigors, and marked torticollis. He had mild trismus and stridor. Oropharynx and larynx were normal apart from gross supraglottic erythema. Blood cultures were taken; he was immediately started on intravenous Cefuroxime and metronidazole and within an hour of admission underwent computed tomography (CT) neck with contrast; this confirmed a 8 x 5 parapharyngeal abscess and thrombosis of his internal jugular vein thrombosis (IJV; Figs. 2 and 3). A provisional diagnosis of possible Lemierre syndrome (LS) was made, and the microbiologists were contacted. The antibiotics were changed to Tazosin and Clindamycin, and he underwent incision and drainage of the abscess via an external approach under general anesthesia with a laryngeal mask. The neck pus grew Fusobacterium necrophorum and Gram-negative bacteria, and the diagnosis of LS was confirmed. The patient improved within 3 days of the operation and was discharged on day 5 on a 2-week course of Augmentin as suggested by the microbiologists. He remains well 6 months later.

The presentation of LS is in the form of any oropharyngeal infection and can manifest with a variety of nonspecific head

and neck symptoms including sore throat, neck mass, neck pain suggesting IJV thrombosis, otalgia and/or otorrhea, dental ache, orbital pain but also bone/joint pain, limb weakness, and even Gastrointestinal symptoms [1]. Systemic complications of LS are important to remember because they often lead to multiorgan failure with extremely high morbidity, Prolonged hospitalization, and not uncommonly death. These include (1) Deep neck space infections; (2) Septic arthritis and osteomyelitis affecting the humerous, hip, clavicle, tibia, and fibia; (3) brain manifestations including meningitis, epidural/ subdural abscess, cavernous/sigmoid/transverse/lateral sinus thrombosis, and stroke; (4) lung manifestations including mediastinitis, pulmonary embolism, empyema, hydro/pneu- mothorax, and pneumonia; (5) eye manifestations including uveitis, vitreous hemorrhage, retrobulbar mass, and VI nerve palsy; (6) liver and spleen manifestations including infarcts and abscesses, and (7) lower cranial nerve (XI-XII) palsies. The treatment–depending on the presentation–is often surgical (ie, draining a neck abscess, intercostal drainage of a pneumothorax, etc) with aggressive Intravenous antibiotics, based on microbiologist advice and targeting fusobacterium necrophorum when appropriate with anticoagulation, al- though the latter remains controversial [1,2].

Any case of oropharyngeal infection accompanied by evidence of IJV thrombosis (preferably on CT scan), thus

Fig. 1 Left parapharyngeal abscess.

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844.e2 Case Report

Fig. 2 Axial CT neck with contrast showing a massive heterogenously enhancing lesion in the left side of the neck involving the Soft tissues only compatible with an abscess and measuring 8 x 5 cm approximately. The airway is not compromised.

Fig. 3 Coronal CT neck showing the cervical segment (3.8 cm) of the left jugular vein occluded in the midneck on the left.

mimicking LS, should be treated as provisional LS without waiting for the final microresults. Microbiology consultation is paramount in these cases to prevent morbidity or mortality often witnessed in these cases.

Petros D. Karkos PhD Department of Otolaryngology Royal Liverpool University Hospital Liverpool, United Kingdom

E-mail address: [email protected]

Christos D. Karkos PhD

Department of Vascular and Endovascular Surgery

Hippocrateio Hospital Thessaloniki, Greece

Samuel C. Leong DO-HNS

Nagaraj Sivaji MD Department of Otolaryngology Royal Liverpool University Hospital Liverpool, United Kingdom

Dimitrios Papadopoulos MD

Intensive Care Unit Larissa General Hospital

Larissa, Greece

Assimakis D. Assimakopoulos

Medical School of Ioannina

Ioannina, Greece

doi:10.1016/j.ajem.2009.11.024

References

  1. Ramirez S, Hild TG, Rudolph CN, et al. Increased diagnosis of Lemierre syndrome and other Fusobacterium necrophorum infections at a children’s hospital. Pediatrics 2003;e380:112.
  2. Goldenberg NA, Knapp-Clevenger R, Hays T, et al. Lemierre’s and Lemierre’s-like syndromes in children: survival and Thromboembolic outcomes. Pediatrics 2005;116:e543-8.