Lemierre’s syndrome

Mugundan. P.T1, Vidya Saketharaman2

1Emergency Medicine resident, Department of Emergency Medicine, Kauvery Hospital, Chennai

2Consultant – Department of Emergency Medicine, Kauvery Hospital, Chennai

Abstract

Lemierre’s syndrome is a condition characterized by thrombophlebitis of the internal jugular vein and bacteremia caused by primarily anaerobic organisms, following a recent oropharyngeal infection. Modern physicians have forgotten this disease. It mostly affects children, adolescents and young adults. Lemierre’s syndrome should be suspected in young healthy patients with prolonged symptoms of pharyngitis followed by symptoms of septicemia or pneumonia. Treatment involves prolonged antibiotic therapy occasionally combined with anticoagulation. We review a case of a gentleman with Lemierre’s syndrome.

Case presentation

A 45- years-aged gentleman presented to our emergency department with history of low grade fever for past 20 days, associated with breathlessness. He had history of hemoptysis on and off with desaturation (SpO2 – 84%). He had history of nasal allergy (nasal discharge with sneezing) on and off for many years.

Initially patient went to a nearby hospital

CT – chest and CT pulmonary angiogram done outside showed multiple focal cavities with consolidation, both lung septic emboli and acute thrombus in right IJV.

HbsAg was positive

He was treated with intravenous meropenem, doxycycline, linezolid and Fluconazole.

Blood culture done outside showed Citrobacter and staphylococcus aureus.

In view of recurrent fever patientwas referred here for further management.

On Examination

General examination: Patient was conscious, oriented, afebrile, hydration fair

APatent
BRR: 16/min, SpO2: 95% at room air, Bilateral basal decreased air entry present, no added sounds
CPeripheral pulses well felt, HR - 64 /min, systolic BP: 130/80 mmHg.
DConscious, obeying to commands, E4V5M6 (15/15), pupils equally reacting equally to light, measuring 3mm,
EThroat – normal, no tonsillar enlargement, no lymphadenopathy

Lab Investigations

Blood investigations on admission;

Hb12.6
PCV37.0
WBC16,790
PLT2,28,000
Sodium136
Potassium 4.10
Urea24.87
Creatinine 0.62

Initial management

  • He was treated with intravenous Meropenem 1 gm TDS, Linezolid 600 mg BD, Clexane 0.6 ml BD, and shifted to ICU for further management.
  • In ICU, specialist advice (Vascular, Cardio, Pulmonology, Dental and ENT) was obtained.
  • Vascular team opinion: Advised to continue intravenous Clexane 0.6ml BD.
  • Trans esophageal echocardiography was advised by Cardiologist – which showed mobile, variably echogenic, mass in main pulmonary artery attached to MPA wall, measures about 19mm–10mm? Clots? Vegetation.

  • CT Carotid and Cerebral A ngiogram showed  – thrombophlebitis of the right internal jugular vein extending into right sigmoid, transverse sinuses upto the torcula, with multifocal septic emboli in both

  • ENT and Dentals were opinions were obtained for any other source of infection; there was no active infective foci.
  • Patient was in hospital for 6 days; he had fever spike till the 3rd day of hospital stay, initial blood culture showed no growth.
  • During the last 3 days of hospital stay the patient had no fever spikes; his oxygen saturation was maintained.

Blood investigation at discharge

Hb10.7
PCV31.9
WBC11,600
PLT2,74,000
Sodium134
Potassium 4.31
Urea17.69
Creatinine 0.57

The risk of bleeding (intracerebral, GI and other mucosal bleed) was explained

He was discharged on intravenous Ceftazidime 2gm TDS, Linezolid 600mg BD, Clexane 0.6ml and review after 1 week. On follow up his blood, culture showed no growth.

Discussion

Lemierre’s syndromeis a rare but serious condition that primarily affects young, otherwise healthy individuals. It is characterized by a sequence of events starting with an oropharyngeal infection, most commonly a sore throat or tonsillitis, leading to septic thrombophlebitis of the internal jugular vein and subsequent metastatic infections.

Diagnostic Criteria: Classic imaging triad of Lemierre’s disease

Lemierre’s syndrome was named after André Lemierre, a French bacteriologist, who first described the condition in 1936. In his seminal paper, Lemierre detailed the association between oropharyngeal infections and secondary septicemia with metastatic abscesses, emphasizing the critical role of the bacterium Fusobacterium Necrophorum as it is the common micro – organism that causes the infection.

Primary sources of infection include the lungs, middle ear, mastoid, teeth and sinuses. Following the primary infection, there is local invasion of the lateral pharyngeal space and septic thrombophlebitis of the IJ vein.

Etiopathogenesis

Flowchart obtained from Microbewik

Common presenting symptoms

Sore throatPleuritic chest pain
Neck massDyspnea
Neck painCough/hemoptysis
Ear painBone/joint pain
Dental painAbdominal pain

Complications

Septic EmboliPulmonary Embolism
Septic ShockCharacterized by hypotension, multi-organ dysfunction, and high mortality.
Persistent Thrombosis and Vascular ComplicationsPersistent Internal Jugular Vein Thrombosis
Neurological ComplicationsCerebral Abscesses and Meningitis
Other Systemic ComplicationsAcute Respiratory Distress Syndrome (ARDS)

Renal Failure
  • While Lemierre’s syndrome is more treatable today, it can still be a life-threatening condition. Hospital admission to an intensive care unit may be necessary. The average length of hospitalization for Lemierre’s is approximately three weeks.
  • The duration of antibiotic therapy should be from 2 to 6 weeks

Sugested empiric antibiotic options for Lemierre’s syndrome

Metronidazole
Clindamycin
Penicillin + Metronidazole
Ampicillin + sulbactam
Ticarcillin + clavulanate
Imipenem
  • Diagnosis is often confirmed by the identification of IJ vein thrombophlebitis by an imaging study and growth of anaerobic bacteria on blood culture. Prolonged antibiotic therapy is the cornerstone of treatment, occasionally combined with anticoagulation.
  • Surgical intervention is rarely needed. Although surgical therapy is secondary, vascular surgeons should be aware of this syndrome to start off with anticoagulation;
  • Hospitalizations for advanced Lemierre’s typically involve stays in intensive care units, and the disease can cause permanent long-term damage.

Take Home points

Oropharyngeal infection – history of sore throat, tonsillitis, pharyngitis, or dental infection within the preceding 1-3 weeks.

Laboratory findings: elevated white blood cell count, positive blood culture, often showing fusobacterium necrophorum but can also include other anaerobic bacteria

Treatment: Antibiotic Therapy, Management Of thrombophlebitis, supportive care – vasopressors in septic shock, surgical management.

Complications: Most common cause septic emboli, septic shock, ARDS, and renal failure.

References

  1. . Lemierre,On Certain Septicæmias Due To Anaerobic Organisms. The Lancet. 1936; 227(5874): 701-703
  2. Osowicki J, Kapur S, Phuong LK, Dobson S. The long shadow of lemierre’s syndrome. J Infect. 2017;74 Suppl 1:S47-S53.
  3. Kuppalli K, Livorsi D, Talati NJ, Osborn M. Lemierre’s syndrome due to Fusobacterium necrophorum. Lancet Infect Dis. 2012;12 (10):808-815.
  4. Wright WF, Shiner CN, Ribes JA. Lemierre syndrome. South Med J. 2012;6(5):283–288. doi: 10.1097/SMJ.0b013e31825581ef.
  1. Hagelskjaer Kristensen L, Prag J. Lemierre’s syndrome and other disseminated Fusobacterium necrophorium infections in Denmark: a prospective epidemological and clinical survey. Eur J Clin Microbiol Infect Dis. 2008;6(9):779–789.
  2. Moreno S, Garcia Altozano J, Pinilla B, Lopez JC, de Quiros B, Ortega A, Bouza E. Lemierre’s disease: postanginal bacteremia and pulmonary involvement caused by Fusobacterium necrophorum. Rev Infect Dis. 1989;6(2):319–324.
  3. Sinave CP, Hardy GJ, Fardy PW. The Lemierre syndrome: thrombophlebitis of the internal jugular vein secondary to oropharyngeal infection. Medicine (Baltimore) 1989;6(2):85–94.
  4. Hagelskjaer LH, Prag J, Malczyski J, Kristensen JH. Incidence and clinical epidemiology of necrobacillosis, including Lemierre’s syndrome in Denmark 1990–1995. Eur J Clin Microbiol Infect Dis. 1998;6(8):561–565.

Acknowledgement

I thank,

Dr. Aslesha vijaay sheth – HOD, department of emergency medicine – kauvery hospital, Chennai.

Dr. Booma – consultant cardiologist, kauvery hospital, Chennai.

For their support in writing the article

 

Dr.Vidya

Dr. Vidya Saketharaman
Consultant – Emergency Physician

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