Infectious Diseases

High risk and low prevalence diseases: Lemierre’s syndrome

a b s t r a c t

Introduction: Lemierre’s syndrome is a Serious condition that carries with it a high rate of morbidity and even mortality.

Objective: This review highlights the pearls and pitfalls of Lemierre’s syndrome, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

Discussion: Lemierre’s syndrome is a condition marked by septic thrombophlebitis of the internal jugular vein , with the classic triad of pharyngotonsillitis, IJV thrombosis, and septic emboli resulting in metastatic abscess. It typically begins as pharyngitis, often caused by Fusobacterium necrophorum. Patients most commonly present with fever, recently diagnosed pharyngitis, and neck pain or swelling. Septic emboli may affect multiple organ systems, most commonly the Pulmonary system. The disease should be considered in patients with prolonged symptoms of pharyngitis, pharyngitis that improves but then worsens, critically ill patients with phar- yngitis, patients with pharyngitis and infection at a secondary site, and neck signs/symptoms. Diagnosis includes throat and blood cultures, as well as imaging to include computed tomography of the neck and chest with intra- venous contrast. Additional imaging of other areas should be performed as clinically indicated. Initial manage- ment includes hemodynamic stabilization with intravenous fluids and vasopressors as needed, as well as broad-spectrum antibiotics. Anticoagulation for the primary thrombus and possible septic emboli is controversial and should be considered in a multidisciplinary approach with admission.

Conclusions: An understanding of Lemierre’s syndrome can assist emergency clinicians in diagnosing and manag- ing this potentially deadly disease.

Published by Elsevier Inc.

  1. Introduction

This article series addresses high risk and low prevalence diseases that are encountered in the emergency department (ED). Much of the primary literature evaluating these conditions is not emergency medicine focused. By their very nature, many of these Disease states and clinical presentations have little useful evidence available to guide the emergency physician in diagnosis and management. The format of each article defines the disease or clinical presentation to be reviewed, provides an overview of the extent of what we currently understand, and finally discusses pearls and pitfalls using a question and answer format. This article will discuss Lemierre’s syndrome, a constellation of findings centered around post-pharyngitis septic thrombophlebitis. This condition’s low prevalence but high morbidity, as well as its vari- able atypical Patient presentations and challenging diagnosis, makes it

* Corresponding author at: 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234.

E-mail address: [email protected] (B. Long).

a high risk and low prevalence disease. The aim of this paper is to provide emergency clinicians with clinical knowledge concerning this rare but potentially lethal condition so that they can diagnose this con- dition expeditiously and provide acute stabilization and management.

    1. Definition

Lemierre’s syndrome most commonly refers to septic thrombo- phlebitis of the internal jugular vein (IJV), with the classic triad of pharyngotonsillitis, IJV thrombosis, and septic emboli resulting in metas- tatic abscess [1]. However, there is no standardized definition for the syndrome with variable criteria utilized throughout the literature [2-4]. The condition most commonly begins with an oropharyngeal infection, but other infections have been associated with the disease [1,5-7].

    1. Pathophysiology

Andre Lemierre published a case series in 1936 of 20 patients (of which 18 died) with post-pharyngitis anaerobic sepsis and IJV

https://doi.org/10.1016/j.ajem.2022.08.050 0735-6757/Published by Elsevier Inc.

thrombosis, although similar presentations were reported as early as 1898 [8-10]. Fusobacterium necrophorum, an obligate anaerobic gram negative rod often found as part of the normal oral flora, is the most common cause of Lemierre’s syndrome, isolated in 48-82% of cases, as well as the most common cause of anaerobic septicemia originating from the oropharynx [2,4,5,8,11-13]. Fusobacterium necrophorum has several factors that increase its virulence including adhesins, endotoxins, leukotoxins, and hemolysins, which increase its ability to cause a necrotic abscess [2-5,10,13]. This microbe can also produce beta-lactamase [2-5,10,13]. Polymicrobial cases demonstrate that Fusobacterium necrophorum-produced leukotoxin can facilitate the growth of aerobic Streptococci and other microbes [3,10,14]. Other bacterial causes include streptococci, Eikenella corrodens, Klebsiella pneu- monia, Bacteroides species, and Staphylococcus aureus [14-16]. Several reports propose that preceding localized infections, to include Infectious mononucleosis caused by Epstein-Barr virus (EBV), weaken oropharyn- geal tissue integrity and the local immune response, allowing for direct penetration and extension of the bacterial infection [8,10,11,13,15,17-21]. The causative microbe enters through the oropharyngeal mucosa via inflammation, trauma, or tissue destruction. The organism then spreads through deep connective cervical tissues into the local hematogenous and/or lymphatic supply, extending to the veins of the head and neck, most commonly the IJV [5-7]. The bacteria cause inflammation of the blood vessel wall and activate platelets and the coagulation cascade, leading to thrombus formation. This initial thrombus may result in septic emboli that affect other organs, most commonly the pulmonary

system [13,22].

Large septic thrombus in the IJV and the propensity for metastatic septic emboli in Lemierre’s syndrome create significant concerns for morbidity and mortality. The initially reported mortality of 90% dropped in the modern era largely due to early antibiotic use, but the current mortality rate remains significant, ranging from 2 to 18% [2,8,9,14,21,23,24]. Approximately 52% of patients require a prolonged hospital or intensive care unit (ICU) length of stay (median 25 days) [23]. Literatures suggests diffuse spread of septic emboli, most notably involving the lungs (37-100%), joints (11-27%), and brain (3%) [4,5,8,9,13,15,25,26]. There are no reported cases of a hemodynamically significant pulmonary embolism (PE) [4]. Limited data demonstrate up to 12% of patients experience a recurrence or clinical sequelae after hos- pital discharge, including cranial nerve palsies, paralysis, paresis, limb amputation, or blindness, and case reports describe airway compromise due to Lemierre’s syndrome [2,4,27].

    1. Epidemiology

Overall, Lemierre’s syndrome is rare, with an incidence of 0.8-3.6 cases per 1,000,000 per year [25,28-30]. However, rates are dispropor- tionately concentrated in adolescent populations, with 14.4-16 cases per 1,000,000 per year in persons aged 16-24 years-old compared to

1.4 million cases per 1,000,000 per year in persons over 40 years-old [15,23,25,28,30]. Some studies limit Lemierre’s syndrome diagnosis only to those who reported a preceding oropharyngeal infection, which likely underestimates the rate of diagnosis [2,29]. While some note there is an increasing rate of occurrence, particularly amongst younger populations, overall there are no consistent frequency trends [2,18,25,28,30,31]. Nevertheless, the incidence of Lemierre’s syndrome may be increasing due to several factors, primarily the increasingly con- servative use of antibiotics and decreased rates of tonsillectomies [2,13,18,29].

  1. Discussion
    1. Emergency department presentation

Patients can present with a variety of signs and symptoms, and early in the course of the disease the presentation is nonspecific,

resembling pharyngitis [16]. With its preponderance in younger populations, most cases involve an immunocompetent adolescent presenting with fever (92-100%), persistent or recently resolved pharyngitis with odynophagia that has worsened (82.5-94%), and neck pain and/or swelling (52-69%) [12,15,16,18,19,27,32]. Respira- tory symptoms include dyspnea, cough, pleuritic chest pain, and he- moptysis. Patients can also present with headache, vision changes, cranial nerve palsies, Dental pain, joint pain, abdominal pain, and nausea and vomiting, associated with complications from septic em- boli [4,5,12,15,16,22,27]. Due to illness severity and metastatic com- plications, patients can present with systemic symptoms and Vital sign abnormalities, including fever, tachycardia, and tachypnea [4,5,12,15,16,22,24,27,33]. Patients may also present with jaundice (11-49%) [15]. Table 1 lists conditions that may present in a similar manner.

    1. Emergency department evaluation

ED evaluation initially includes assessment of hemodynamic and airway status and evaluation for the underlying cause of the patient’s symptoms. Oropharyngeal examination may reveal posterior erythema, petechiae, and exudates, but the oropharynx may be normal. Evidence of IJV thrombosis includes unilateral tenderness, swelling, erythema, and induration over the anterior neck, angle of the jaw, or the sternocleidomastoid muscle. This may extend to the face as well [16,21]. However, thrombosis of the IJV is not commonly palpable, and these signs may not be present. Bilateral cervical lymphadenopathy may be present. Patients may present with complications from septic emboli, including pulmonary infection, visual complaints, Septic arthritis (i.e., joint pain, erythema, effusion), or abdominal pain and tenderness. Given the predominance of patients presenting with fever and Abnormal vital signs, concerns for septicemia drive the initial evaluation with blood tests including complete blood count , elec- trolytes, renal and liver function, inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), and lactate [12,16,27]. If Lemierre’s syndrome is suspected, throat cultures and at least two sets of blood cultures should be obtained. Polymerase chain reaction testing can be used to evaluate for Fusobacterium instead of traditional culture [5,34]. Testing of other sites is based on history and examination (e.g., arthrocentesis for septic arthritis). A plain chest radiograph should be obtained and may demonstrate Pleural effusions, nodular infiltrates, cavitary lesions, and pneumothoraces [13,16,21,23,27]. Imaging to eval- uate for IJV thrombosis may include computed tomography (CT) of the neck with intravenous (IV) contrast (Fig. 1) or ultrasound (US) (Fig. 2) [3,12,16,19,32,35]. US can be limited based on the thrombus location (i.e., underneath the clavicle or near the mandible) and the operator, and CT of the neck with IV contrast is the most common imaging modality utilized [21,35]. Given the concern for pulmonary septic emboli in Lemierre’s syndrome, CT of the chest with IV contrast should be obtained, especially in those who demonstrate hypoxemia or other

Table 1

Differential diagnosis considerations.

Image of Fig. 1

Fig. 1. Neck CT demonstrating IJV thrombus. Case courtesy of Dr. Charlie Chia-Tsong Hsu, Radiopaedia.org, rID: 20527.

respiratory symptoms [36-38]. Other imaging studies to evaluate for septic emboli are driven by presentation and physical examination, including CT of the head if the patient has headache or neurologic or cranial nerve deficits and CT of the abdomen and pelvis if the patient has significant abdominal pain or elevated liver function tests [16]. Additionally, the spread of septic emboli beyond the lungs generally targets the joints (13-27%), most commonly the hips, which may be evaluated with arthrocentesis if clinically indicated [2,13,15,16].

    1. Emergency department management

Management of Lemierre’s syndrome includes recognition of septic thrombophlebitis with prompt resuscitation and antibiotic administration. hemodynamic support may be required with fluid resuscitation and vasoactive agents (e.g., norepinephrine) ensuring end organ perfusion. If a Central venous catheter is necessary, a site other than the affected IJV should be utilized [4,39]. Patients

with signs of respiratory distress (tachypnea, dyspnea, hypoxemia) should receive supplemental oxygen. Patients with evidence of airway obstruction, severe respiratory distress, or failure of oxygenation or ventilation should be intubated. Broad-spectrum antibiotics, includ- ing anaerobic coverage, should be initiated in the ED. Emergency clini- cians can consider Anticoagulation management in consultation with admission teams, otolaryngology, and possibly thoracic or vascular surgery [4,8,13-15,19].

  1. Pearls and pitfalls
    1. What infections may lead to Lemierre’s syndrome?

While Fusobacterium necrophorum and other bacteria associated with pharyngotonsillitis are the primary cause of Lemierre’s syndrome, these are common oral flora, and there are a number of other potential etiologies [11,40,41]. Recent or concurrent EBV has been associated

Image of Fig. 2

Fig. 2. Right internal jugular vein (IJV) cranial to thyroid gland level up to skull vault is dilated with hypoechoic thrombus without internal flow. Case courtesy of Dr. Maulik S Patel, Radiopaedia.org, rID: 59512.

with the disease and is likely a facilitator for bacterial penetration of compromised oropharyngeal tissue [4,11,12,19].

Fusobacterium necrophorum is generally found in significant port- ions of asymptomatic populations (21%) and even higher in non- streptococcal pharyngitis (10-48%), which can then incite infection with flora disruption in Viral illness [11,12,40-42]. While Fusobacterium necrophorum is commonly found in the oropharynx, it also resides in the genitourinary and gastrointestinal tracts [13]. This broad spread across multiple systems has led some authors to diagnosis Lemierre’s syndrome with non-pharyngitis origins, including Otitis media, sinusitis, molar extraction, vulvovaginitis, and intravenous drug use [10,24,43,44]. While there is no universal definition of Lemierre’s syn- drome, the vast majority of literature specifies oropharyngeal origin as a criterion for diagnosis [4,12,13,15,16,19,20,24,27,33,35,45]. Therefore, cases stemming from infections of other sites have been described as septic thrombophlebitis without the Lemierre’s syndrome eponym [3].

    1. What are reliable history and examination findings in Lemierre’s syn- drome?

There are a variety of history and examination findings in Lemierre’s syndrome (Table 2). Fever is present in over 90% of cases and can be severe (>= 39C). Patients may have rigors, chills, sore throat, dysphagia, trismus, and Unilateral neck pain and tenderness [36]. Septic emboli can affect several organ systems, and patients may present with complications from these locations. The most common site affected by septic emboli includes the pulmonary system, resulting in pleuritic chest pain and dyspnea [4,5,12,15,16,22,27]. Examination may reveal posterior pharyngeal exudates, hyperemia, or ulcerations, or there may be no oropharyngeal abnormalities [36]. Examination of the neck may reveal erythema, tenderness, and induration, but up to 47% of patients will have no evidence of neck signs or symptoms on initial presentation [32]. Neck swelling and tenderness due to septic thrombo- phlebitis in Lemierre’s syndrome can be mistaken for and dismissed as reactive lymphadenopathy [4,15,22,35,44].

Due to the variation in presentation and signs and symptoms, clini- cians should consider this condition in patients with prolonged symptoms of pharyngitis (7 days), patients with pharyngitis who are critically ill appearing, those with a history of pharyngitis that improves but then worsens, patients with a history of pharyngitis and a second site of infection (e.g., pneumonia, meningitis, renal/Liver abscess, etc.), and those with evidence of soft tissue infection within the neck

Table 2

History, physical examination, and evaluation findings [12,15,32].

History Evaluation

(trismus, neck mass, pain with neck movement, erythema/induration of the neck).

    1. What organ systems can be involved in Lemierre’s syndrome?

pulmonary complications are common, which typically present as necrotic cavitary lesions associated with septic emboli. This may occur in up to 97% of cases [36,37]. Other pulmonary issues include in- filtrates, effusions, empyema, abscess, pneumothorax, and necrotizing mediastinitis [32]. One study found 51% of patients had pleural effusions, while 41% had a lung abscess [38]. Hematogenous spread with or without septic shock can occur [36,46]. Bacteremia can be tran- sient, with 82% of overall cultures yielding an organism [32]. Large joints are the second most common site affected with septic emboli after the pulmonary system [13]. Literature suggests 11-27% of cases will have large joint involvement, most commonly the knees, hips, or shoulders [32,38]. Patients may have sterile Joint effusion, but septic arthritis can occur [32,38]. Cutaneous lesions like soft tissue abscess, pyomyositis, splenic abscess, renal abscess, liver abscess, pericarditis, endocarditis, and mycotic pseudoaneurysm may occur [36,46,47]. Central nervous system (CNS) involvement has been reported including Brain abscess, spinal Epidural abscess, Subdural empyema, cerebral infarction, and meningitis, but this is overall rare [13]. Cerebral venous thrombosis can occur as a result of retrograde extension of the IJV thrombosis. Oph- thalmologic complications can include extraocular motor dysfunction and cranial nerve palsy, proptosis, change in vision, and elevated ocular pressures [48].

    1. What imaging is recommended?

Imaging is an essential component of diagnosis for Lemierre’s syndrome, as septic thrombophlebitis is a mainstay in all proposed definitions of Lemierre’s syndrome diagnosis. Plain chest radiograph is recommended and may demonstrate Pulmonary findings due to septic emboli. CT on the neck with IV contrast is the imaging modality of choice to diagnose thrombosis of the IJV [3,12,16,19,32,35]. CT can visualize the thrombosis length and degree of IJV occlusion, as well as diagnose formation of an abscess. CT of the chest should be obtained to evaluate for septic pulmonary emboli, as well as complications (e.g., necrotic abscess, effusion, mediastinitis, pneumothorax, etc.) [3,12,16,19,27,32,35]. US can rapidly identify an IJV thrombosis, and clinicians may find a dilated IJV with a complex mass of solid and cystic components [35,37]. However, there are limitations with the use of US for diagnosis. An early IJV thrombosis may not be echogenic on US, lead- ing to a false negative imaging result [4,35,49]. There are few studies examining US for diagnosis of IJV thrombosis, and although one study listed sensitivity and specificity as high as 96% and 93%, respectively, when using duplex compression, authors continue to note that US is

      • Fever (82.5-100%)
      • Pharyngitis (82.5-94%)
      • Myalgias/arthralgias (69%)
      • Pleuritic chest pain (31.1%)
      • Dyspnea (23.8-25%)
      • Diarrhea (19.2%)
      • Nausea & vomiting (18.3%)
      • Dysphagia (17.4%)
      • Hemoptysis (8.2%)

Physical examination

      • Cervical lymphadenopathy (33-75%)
      • Swollen and/or tender neck (52.2-69%)
      • Hepatosplenomegaly (15.5%)
      • Hypoxemia (19.2%)
      • Hypotension (14.6%)
      • Jaundice (11-49%) Laboratory
      • Leukocytosis (31-75.2%)
      • Hyperbilirubinemia (32.1%)
      • Thrombocytopenia (23.8%)
      • Hematuria (5.5%) Chest radiograph
      • Pleural effusion (43.1%)
      • Bibasilar infiltrates (20.1%)
      • Normal (19.2%)
      • Diffuse infiltrates (17.4%)
      • Diffuse nodules (11.0%)
      • Localized infiltrate (10.0%)

less sensitive than CT [35,50]. US is also limited in obtaining images in regions deep to the clavicle and mandible [35,50]. In patients with neck swelling or concern for Lemierre’s syndrome, clinicians should therefore attempt to visualize secondary sonographic effects of throm- bophlebitis. These include inability to compress the vessel, lack of Color Doppler flow, lack of pulsation, and poor or no venous correlation to respiratory maneuvers [4,35,49,51]. Lemierre’s syndrome can be complicated by significant septic emboli to the brain, lungs, and other distal organs, some of which may not be accessible by ultrasound, and thus CT of other involved organs is recommended based on history and examination (e.g., patients with abdominal pain should undergo CT of the abdomen and pelvis with IV contrast).

    1. What are key components of management, and what antibiotics should be utilized in management?

Initial management include resuscitation and assessment of the patient’s airway, allowing the patient to remain in a position of

Table 3

Antibiotic considerations.

antibiotic regimens

  1. Piperacillin tazobactam 3.375 g IV every 6 h OR
  2. Imipenem 500 mg IV every 6 h OR Meropenem 1 g IV every 8 h OR Ertapenem 1 g IV every 24 h

OR

2. Ceftriaxone 2 g IV every 24 h PLUS Metronidazole 500 mg IV every 8 h

Hemodynamic instability:

Add Vancomycin 20 mg/kg IV to one of the above choices

CNS involvement:

Ceftriaxone 2 g IV every 24 h PLUS Metronidazole 500 mg IV every 8 h PLUS Vancomycin 20 mg/kg IV

comfort. oxygen supplementation and even endotracheal intubation may be needed for patients with respiratory distress, airway obstruc- tion, or failure to oxygenate or ventilate. Intravenous fluid resuscitation and vasopressors may be required in patients with hemodynamic in- stability. Emergency clinicians should administer broad-spectrum antibiotic coverage for patients with evidence of sepsis based on the most common sources of infection (i.e., pulmonary and urinary tract) and patient factors (i.e., long term care facility resident, immunocom- promised state, etc.). While there is no firm societal consensus or consistent author recommendations on antibiotic therapy, Empiric treatment for those with suspected Lemierre’s syndrome should target Fusobacterium necrophorum, Bacteroides and other anaerobic species, and oral streptococci, with a regimen resistant to beta-lactamase (Table 3) [4,8,10,11,14,15,20,24,41]. Proposed options within the liter- ature include adding metronidazole to penicillin-based coverage or clindamycin monotherapy [3,4,8,12,13,20,51]. In a single retrospective study of 394 patients with Lemierre’s syndrome over 27 years, the most-utilized antibiotics were metronidazole (21%) and clindamycin (16%) [8]. In selecting anaerobic coverage, some authors propose preference for metronidazole given its enhanced tissue penetration, including into septic clots, which is not found in clindamycin [5,19,22]. We recommend using piperacillin-tazobactam, a carbapenem (e.g., ertapenem, imipenem, or meropenem), or ceftriaxone plus metronida- zole (Table 3) [24,51]. resistance rates for ampicillin-sulbactam have in- creased, and thus this agent is not recommended [52,53]. If patients are hemodynamically unstable, vancomycin should be added for methicillin- resistant S. aureus (MRSA) coverage. If CNS involvement is suspected, vancomycin, ceftriaxone, and metronidazole are recommended.

    1. What type of anticoagulation is recommended?

The identification of IJV thrombosis, as well as potential for other emboli in Lemierre’s syndrome, requires consideration of anticoagula- tion to mitigate Clot burden and propagation. However, there is no clear consensus or society Guideline recommendations for or against anticoagulation, and no significant trials exist evaluating anticoagulant use in Lemierre’s syndrome [14,15,20,39]. Authors are often directly at odds in their arguments, with some proposing that anticoagulation will prevent disseminated septic emboli, while others caution that these medications will result in thrombolysis, propagation and spread of smaller septic emboli, and even concentrated bacterial release from the dissolved thrombus [2,3,18-20,54,55]. Ironically, some argue that bacterial release from anticoagulation-induced thrombolysis would be beneficial for increased antibiotic efficacy [19,20,51]. Scant comparative studies, mostly small case series, generally demonstrate no significant benefit from anticoagulant use [3,39,55]. Anticoagulation is adminis- tered in 21-63% of cases, most commonly low molecular weight hepa- rin, although use of unfractionated heparin, warfarin, and rivaroxaban has been reported in the literature [8,14,15,20,39,45].

The decision for anticoagulation should be made in consultation with the otolaryngology specialist, hematology specialist, and the

Table 4

Lemierre’s syndrome pearls.

  • The classic triad of Lemierre’s syndrome includes pharyngotonsillitis, IJV thrombosis, and septic emboli resulting in metastatic abscess.
  • While pharyngotonsillitis is the most common infection associated with Lemierre’s syndrome, other infections may result in IJV thrombosis.
  • Lemierre’s syndrome should be considered in patients with prolonged symptoms of pharyngitis (7 days), critically ill patients with pharyngitis, those with a history of pharyngitis that improves but then worsens, patients with a history of pharyngitis and a second site of infection (e.g., pneumonia, meningitis, renal/liver abscess, etc.), and those with evidence of soft tissue infection within the neck (trismus, neck mass, pain with neck movement, erythema/induration of the neck).
  • The imaging modality of choice includes CT of the neck and chest with IV contrast; US can assist but has significant limitations.
  • Septic emboli can result in pulmonary complications, septic arthritis, soft tissue

abscess, pyomyositis, Intra-abdominal abscess, Ocular complications, and CNS complications.

  • Treatment includes resuscitation, assessment of the airway and intervention if needed, broad-spectrum antibiotics, and consideration of anticoagulation.

admitting physician. Anticoagulation is likely necessary in patients with progression of thrombosis, continued fever, or worsening symp- toms after 5-7 days of appropriate antibiotics. The optimal duration of anticoagulation is also unknown, but anticoagulation may be discontinued if the patient has clinically improved and there is no fur- ther extension of thrombus on imaging. Durations over 6 weeks may be needed in patients with embolic disease or other risk factors increas- ing the risk of thrombosis. No available literature extensively discusses Anticoagulation contraindications in those with Lemierre’s syndrome; however, existing considerations for malignancy, recent surgery, and/ or disseminated intravascular coagulopathy should be discussed with consultants on admission.

    1. What are other treatment options?

Patients may require interventional or surgical treatment in several circumstances. Patients with purulent fluid collections will require drainage, while those with necrotic tissue require debride- ment [13,56-58]. Pulmonary complications including empyema should undergo drainage [13,56,57]. If the patient continues to clinically deteriorate or if septic emboli continue to occur despite antibiotics and anticoagulation, the affected IJV may require exci- sion or ligation, though this is considered a last resort [8,32,37,59]. One study found that less than 0.03% of patients require IJV excision or ligation [8].

Table 4 lists pearls regarding the evaluation and management of Lemierre’s syndrome.

  1. Conclusion

Despite its rarity and improved Treatment regimens, Lemierre’s syndrome is associated with significant morbidity and even mortal- ity. Lemierre’s syndrome is associated with septic thrombophlebitis, primarily of the IJV, and risk of disseminated septic emboli. History and examination can vary but largely center on an ill-appearing patient with neck signs and symptoms, possibly with ongoing phar- yngitis. Evaluation includes throat and blood cultures with imaging. Ultrasound can identify IJV thrombosis, but the first-line imaging modality is CT of the neck with IV contrast. Additional CT imaging is indicated for other systems when concerned for infection or embolus. Immediate management focuses on Hemodynamic resuscitation as clinically indicated with intravenous fluids and vasoactive medica- tions if needed to maintain adequate systemic perfusion, broad- spectrum antibiotics with anaerobic coverage, and consideration of anticoagulation. All patients require admission, likely to an ICU, for continued medical management.

CRediT authorship contribution statement

Brandon M. Carius: Writing – review & editing, Writing – original draft, Visualization, Conceptualization. Alex Koyfman: Writing – review & editing, Visualization, Validation, Conceptualization. Brit Long: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Conceptualization.

Declaration of Competing Interest

None.

Acknowledgements

BMC, BL, AK conceived the idea for this manuscript and contributed substantially to the writing and editing of the review. This manuscript did not utilize any grants, and it has not been presented in abstract form. This clinical review has not been published, it is not under consideration for publication elsewhere, its publication is approved by all authors and tacitly or explicitly by the responsible authorities where the work was carried out, and that, if accepted, it will not be published elsewhere in the same form, in English or in any other language, including electroni- cally without the written consent of the copyright-holder. This review does not reflect the views or opinions of the U.S. government, Depart- ment of Defense or its Components, Defense Health Agency, U.S. Army,

U.S. Air Force, Madigan Army Medical Center, or Brooke Army Medical Center.

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