A unique case of Lemierre's syndrome status post blunt cervical trauma.

BACKGROUND: Lemierre's syndrome is a rare but potentially fatal condition. The course is characterized by acute tonsillopharyngitis, bacteremia, internal jugular vein thrombosis, and septic embolization. There have been some cases secondary to penetrating trauma to the neck. Literature review has yielded no cases secondary to blunt neck trauma in the absence of oropharyngeal injury. We aim to shed light on this unique cause of Lemierre's syndrome, so as to raise the index of suspicion for clinicians working up patients with blunt cervical trauma. METHODS: We present a case of a 25-year-old male restrained driver who presented with left neck and shoulder pain with a superficial abrasion to the left neck from the seatbelt who was discharged same day by the Emergency Room physicians. He returned to the Emergency Department two days later with abdominal pain. As a part of his repeat evaluation, a set of blood cultures were sent and was sent home that day. The patient was called back to the hospital one day later as preliminary blood cultures were positive for Gram positive cocci and Gram negative anaerobes. Computerized tomography scan of the neck revealed extensive occlusive left internal jugular vein thrombosis and fluid collections concerning for abscesses, concerning for septic thrombophlebitis. The patient continued to decompensate, developing severe sepsis complicated by disseminated intravascular coagulation. RESULTS: The patient underwent a left neck exploration with en bloc resection of the left internal jugular vein, drainage of abscesses deep to the sternocleidomastoid, and washout/debridement of necrotic tissue. Direct laryngoscopy at the time of surgery revealed no injury to the aerodigestive tract. Wound cultures were consistent with blood cultures and grew Fusobacterium necrophorum, Staphylococcus epidermidis, and Methicillin-resistant staphylococcus aureus. The patient underwent two subsequent operative wound explorations without any evidence of residual infection. The patient was discharged home on postoperative day 13 on a course of antibiotics and aspirin. CONCLUSION: This case illustrates the importance of diagnosis of Lemierre's syndrome after an unconventional inciting event (blunt cervical trauma) and appropriate treatment.

Lemierre's syndrome: a rare cause of sepsis presenting with an absence of throat symptoms.

A 16-year-old boy presented to hospital with a 6-day history of diarrhoea, vomiting and abdominal pain. During his admission he was found to be hypotensive, tachycardic and persistently feverish. Blood cultures taken on admission isolated Fusobacterium necrophorum CT scanning of his neck showed a non-occlusive thrombus of the right internal jugular vein and a small right parapharyngeal abscess. CT scans of the chest and abdomen revealed multiple pulmonary abscesses, bilateral pleural effusions and splenomegaly. Treatment consisted of an unfractionated heparin infusion and intravenous antibiotics. A right-sided intercostal drain was inserted for a complex right-sided empyema. He subsequently developed a left-sided pleural effusion which was treated with a video-assisted thoracoscopic surgery (VATS) pleurodesis procedure. His fever resolved after his VATS pleurodesis procedure 3 weeks after initial presentation. Clinically he made a slow recovery but now is improved after 6 weeks of intravenous antibiotics and was discharged home.

Lesson of the month 1: Lemierre's syndrome: a reminder of the 'forgotten disease'.

Lemierre's syndrome is a condition characterised by suppurative thrombophlebitis of the internal jugular (IJ) vein following a recent oropharyngeal infection, with resulting septicaemia and metastatic lesions. It is strongly associated with Fusobacterium necrophorum, a Gram-negative bacilli. Key to early diagnosis is awareness of the classical history and course of this illness, and therefore to ask about a history of recent oropharyngeal infections when a young patient presents with fever and rigors. Diagnosis can be confirmed by showing thrombophlebitis of the IJ vein, culturing F necrophorum from normally sterile sites or demonstrating metastatic lesions in this clinical setting. The cornerstone of management is draining of purulent collection where possible and prolonged courses of appropriate antibiotics. In this article, we review a case study of a young man with Lemierre's syndrome and discuss the condition in more detail.

Lemierre Disease: A Case With Multilevel Epidural Abscess and Aggressive Neurological Weakness: Case Report and Literature Review.

BACKGROUND: Lemierre disease is a rare postanginal sepsis caused by the anaerobe Fusobacterium necrophorum. It is associated with a pharyngitis that progresses quickly to thrombophlebitis of the internal jugular vein and metastatic abscesses to pulmonary, soft tissue, articular, and organ systems. It is rarely associated with spinal epidural abscesses. Because of the increasing antibiotic resistance, its incidence is on the rise. METHODS: A single-patient case report of an adolescent male who initially presented to our institution for bacteremia and febrile episodes. Over a 1-week course, he developed severe back pain and progressive lower extremity weakness. Advanced imaging revealed an epidural abscess spanning T2-L3 level with extension into the psoas and the paraspinal musculature. Acute management consisted of broad-spectrum intravenous (IV) antibiotics and hemilaminectomy decompression from T2 to L3. The patient completed a 6-week course of IV antibiotics and was followed for a 1-year time period with close clinical follow-up. RESULTS: Blood cultures identified the infecting organism as F. necrophorum. The combination of IV antibiotics and acute hemilaminectomy decompression resulted in successful clearance of the infecting organism with normalization of inflammatory markers and cultures. The patient noted immediate and sustained neurological improvement, with return of full motor and sensory function. At the 1-year timepoint, the patient was able to return to sports and no sagittal/coronal imbalance was noted on radiographs. CONCLUSIONS: An aggressive case of Lemierre disease with extensive epidural abscess formation and neurological weakness was successfully managed with the combination of IV antibiotics and extensive hemilaminectomies for decompression. The patient exhibited no long-term sequela as a result of either the epidural abscess or of its treatment. LEVEL OF EVIDENCE: Level V.

Lemierre's Syndrome Associated Mycotic Aneurysm of the External Carotid Artery with Primary Internal Carotid Artery Occlusion in a Previously Healthy 18-Year-Old Female.

Lemierre's syndrome is a rare life-threatening condition characterized by internal jugular vein thrombosis and is typically associated with a gram-negative infection with septic metastasis secondary to a retropharyngeal abscess that involves the vasculature of the head and neck. We report a case of Lemierre's syndrome in an 18-year-old female adolescent who developed an internal carotid artery occlusion and ipsilateral external carotid artery (ECA) mycotic aneurysm complicated by fulminant pseudomonal sepsis. The patient was managed with open ligation of the ECA with essentially complete recovery.

The forgotten disease - Lemierres syndrome.

Lemierre's syndrome refers to septic thrombosis of deep veins of the neck, is a rare and often life threatening complication following upper respiratory tract infections. We present here a case of Lemierre's syndrome in a previously healthy 30 years old female who had a febrile illness for two weeks with associated dysphagia, hoarse voice and right sided neck swelling. She was investigated for retropharyngeal and parapharyngeal abscess, granulomatosis with polyangiitis, tuberculosis and thyroiditis but finally concluded as Lemierre's syndrome based on the findings of thrombosis of the deep neck veins following respiratory tract infection, septic pulmonary emboli and clinical recovery with antibiotics and supportive care. Lemierres syndrome can be fatal if diagnosis and treatment is delayed. Strong clinical suspicion leads to early diagnosis and may prevent life threatening organ dysfunction.

Síndrome de Lemierre: relato de caso / Lemierre syndrome: a case report

A tromboflebite supurativa da veia jugular interna ou síndrome de Lemierre foi descrita pela primeira vez em 1900. O evento inicial mais frequente é a infecção de orofaringe associada à trombose da veia jugular interna. Embora uma entidade rara, a síndrome de Lemierre continua a ser uma doença de morbidade e mortalidade consideráveis devido à sua progressão e atrasos de diagnóstico.

Suppurative thrombophlebitis of the internal jugular vein, or Lemierre syndrome, was described for the first time in 1900. The most common initial event is an infection of the oropharynx associated with thrombosis of the internal jugular vein. While it is a rare entity, Lemierre syndrome remains a disease that causes considerable morbidity and mortality, due to its progression and to delays in diagnosis.

Importance of blood cultures to aid the diagnosis of Lemierre's syndrome.

This is a case report of Lemierre's syndrome, a septic thrombophlebitis of the internal jugular vein (IJV) usually preceded by pharyngitis and bacteraemia with an anaerobic organism. Fusobacterium necrophorum is ananaerobic Gram-negative bacillus and is the most common organism reported to cause Lemierre's syndrome which usually occurs one to three weeks post pharyngitis or oropharyngeal surgery. A 21-year-old patient presented with signs of sepsis and a history of sore throat, fever, and tender cervical lymph nodes. Blood cultures grew F. necrophorum and Computed Tomography (CT) showed a filling defect in the left retromandibular vein and thrombosis in the left internal jugular vein (IJV) consistent with Lemierre's syndrome. This is an uncommon condition which normally occurs in young individuals and diagnosis is often delayed.

[Lemierre syndrome revealed by torticollis]. / Syndrome de Lemierre révélé par un torticolis.

Classical Lemierre syndrome is a rare and severe disease with thrombosis of the internal jugular vein and metastatic infections. We report on a case of Lemierre-like syndrome secondary to mastoiditis, with a favorable outcome, in a healthy infant presenting with torticollis. Early diagnosis and treatment with antibiotics are necessary to decrease mortality.

Septic thrombosis of the internal jugular vein: Lemierre's syndrome revisited.

OBJECTIVES/HYPOTHESIS: Study of the clinical evolution of a primary ear, nose, and throat infection complicated by septic thrombophlebitis of the internal jugular vein. STUDY DESIGN: Retrospective case-control study. PATIENTS AND METHODS: From 1998 to 2010, 23 patients at our institution were diagnosed with a septic thrombosis of the internal jugular vein. Diagnostics included microbiologic analysis and imaging such as computed tomography, magnetic resonance imaging, and ultrasound. Therapy included broad-spectrum antibiotics, surgery of the primary infectious lesion, and postoperative anticoagulation. The patients were retrospectively analyzed. RESULTS: The primary infection sites were found in the middle ear (11), oropharynx (8), sinus (3), and oral cavity (1). Fourteen patients needed intensive care unit treatment for a mean duration of 6 days. Seven patients were intubated, and two developed severe acute respiratory distress syndrome. An oropharynx primary infection site was most prone to a prolonged clinical evolution. Anticoagulation therapy was given in 90% of patients. All 23 patients survived the disseminated infection without consecutive systemic morbidity. CONCLUSION: In the pre-antibiotic time, septic internal jugular vein thrombophlebitis was a highly fatal condition with a mortality rate of 90%. Modern imaging techniques allow early and often incidental diagnosis of this clinically hidden complication. Anticoagulation, intensive antibiotic therapy assisted by surgery of the primary infection site, and intensive supportive care can reach remission rates of 100%.

Lemierre syndrome: study of 11 cases and literature review.

BACKGROUND: Lemierre syndrome is a rare but serious illness that associates throat infection and thrombosis of the internal jugular vein (IJV) or one of its tributaries with subsequent distant septic emboli. The purpose of our study was to review the pathogenesis, clinical presentation, and treatment of this disease. METHODS: Patients with confirmed Lemierre syndrome were included in our retrospective monocentric study. All patients had bacteriologic analyses as well as radiologic imaging. RESULTS: There were 11 patients in our study (from 1998-2012). Fusobacterium necrophorum was responsible for the infection in 45% of cases. Surgical drainage of pharyngeal, cervical, or mediastinal abscesses was carried out in 8 cases. All patients received broad-spectrum antibiotics. Six patients were admitted to the intensive care unit (ICU). One patient (9%) died. CONCLUSION: Treatment with broad-spectrum antibiotics is the primary choice of treatment of Lemierre syndrome. Surgery is indicated in case of abscess formation.

Síndrome de Lemierre: reporte de un caso / Lemierre syndrome: a case report / Lemierre syndrome: A case report

El síndrome de Lemierre es una complicación muy poco frecuente de una infección orofaríngea, que progresa con tromboflebitis séptica secundaria e infecciones embólicas frecuentes. Presentamos el caso de una mujer de 20 años que inició un cuadro de odinofagia y fiebre, el cual progresó rápidamente a un absceso periamigdalino con trombosis de la vena yugular interna ipsilateral, embolias sépticas pulmonares y meningitis. Se manejó con drenaje del absceso por punción, terapia antibiótica de amplio espectro y anticoagulación respondiendo favorablemente, siendo dada de alta en buenas condiciones luego de 35 días de hospitalización. Con la terapia antimicrobiana, casos como éste son poco frecuentes, incluso a veces olvidados, pero dado su gravedad deben considerarse en cuadros faríngeos de evolución tórpida o ante la aparición de signos neurológicos o sépticos.

Lemierre syndrome is a rare complication of oropharyngeal infection which progresses with secondary septic thrombophlebitis and embolic infections. A 20 years-old woman started with odynophagia and fever, which progressed rapidly to a peritonsillar abscess with thrombosis of the ipsilateral internal jugular vein, septic pulmonary emboli and meningitis. She was managed with abscess drainage puncture, broad-spectrum antibiotic therapy and anticoagulant responding favorably, and was discharged in good condition after 35 days of hospitalization. Since the use of antimicrobial therapy, cases like these are rare, sometimes forgotten, but given its severity should be considered in pharyngeal torpid illness or at the onset of neurological signs or sepsis.

A 10-month-old with Lemierre syndrome complicated by purulent pericarditis.

Lemierre syndrome is a potentially life-threatening septic thrombophlebitis associated with a neck infection. We present a case of a 10-month-old female infant with Lemierre syndrome complicated by thrombotic strokes and purulent pericarditis. A healthy 10-month-old female infant presented to the pediatric emergency department of our tertiary care center complaining of 5 days of fever to 105°F and 1 day of neck stiffness and decreased oral intake. In the pediatric emergency department, she developed septic shock, requiring vasopressor support, endotracheal intubation, and broad-spectrum antibiotics. A computed tomographic scan demonstrated a neck abscess associated with a right internal jugular thrombus and septic emboli to her lungs and brain. This constellation was consistent with Lemierre syndrome. Further studies demonstrated the thrombus extended into her left ventricular outflow tract. She was emergently taken to the operating room for incision and drainage of her neck abscess, started on anticoagulation with heparin, and eventually transitioned to enoxaparin. Her hospital course was complicated by a middle cerebral artery distribution infarction and subsequent hemorrhagic conversion with generalized tonic clonic seizures managed by levetiracetam. Ten days into her hospital stay, she developed pericardial tamponade, and cardiac surgery performed a pericardial window for loculated, purulent pericardial effusion. Initial blood cultures were positive for methicillin-sensitive Staphylococcus aureus, and the patient was treated with 6 weeks of nafcillin. She has recovered with minimal permanent sequelae. This is one of the youngest cases of Lemierre syndrome documented. To our knowledge, it is also the first case complicated by purulent pericarditis reported in the literature.

Lemierre syndrome.

Lemierre's syndrome is an uncommon complication of pharyngitis in the United States and caused most commonly by the bacterium Fusobacterium necrophorum. The syndrome is characterized by a history of recent pharyngitis followed by ipsilateral internal jugular vein thrombosis and metastatic pulmonary abscesses and is a disease for which patients will seek medical care and advice. As most patients are admitted to the hospital under internal medicine, practitioners should be familiar with the usual signs and symptoms of Lemierre's syndrome along with its diagnosis and treatment. Controversy involves the choice and duration of antimicrobial therapy used for treatment and anticoagulation therapy for internal jugular vein thrombosis. As the diagnosis and management of this syndrome has generated controversy, an updated review of the literature and treatment recommendations may be helpful for providing optimal care for patients with this often unrecognized and confusing infection.

Orbital dissemination of Lemierre syndrome from gram-positive septic emboli.

A 45-year-old patient presented with bilateral orbital abscesses. He was found to have Lemierre syndrome, a condition involving septic thrombophlebitis of the internal jugular vein. The patient developed severe proptosis, sepsis, and cavernous sinus thrombosis. Despite aggressive antibiotic and anticoagulation therapy, visual loss was rapid, and the patient ultimately died. Lemierre syndrome, previously thought to be rare, is now becoming more commonly reported. Its prompt diagnosis and treatment are essential for patient survival.

Severe musculoskeletal infection variant in Lemierre's syndrome.

Lemierre's syndrome is a severe complication of Fusobacterium necrophorum oropharyngeal infection associated with metastatic foci of infection, internal jugular vein thrombosis, and septicemia. Musculoskeletal manifestations include isolated or multifocal septic arthritis, soft tissue abscesses, pyomyositis, and osteomyelitis. This article describes a case of a variant of Lemierre's syndrome in a 17-year-old girl, demonstrating a relentless case of limb infection refractory to multiple surgical debridements and broad-spectrum and targeted antibiotics. The patient had F. necrophorum within a peritonsillar abscess and multiple foci within her right lower extremity. Overall, she required 12 surgical procedures and 14 weeks of antibiotic therapy to resolve the infection. Further unique findings in this case include the presence of a recent lateral meniscus tear with associated hemarthrosis treated with a short course of oral steroids prior to the diagnosis of septic arthritis. Knee arthroscopy with lysis of adhesions and manipulation at 6 months postinfection demonstrated significant chondral damage. Outcome at >2-year follow-up revealed pain-free activities of daily living and the ability to return to competitive, club-level collegiate softball. Clinically relevant findings illustrated in this case include potential development of antibiotic resistance within Fusobacterium genus with little to no response to several surgical debridements and broad-spectrum and targeted antibiotics, and development of multifocal, ipsilateral septic arthritis and soft tissue abscesses and pyomyositis in the context of steroid use and recent intra-articular knee injury.

[Jugular vein thrombosis and Lemierre's syndrome--severe complications of oropharyngeal infections]. / Jugularvenenthrombose und Lemierre-Syndrom--schwerwiegende Komplikationen oropharyngealer Infekte.

BACKGROUND: Acute oral or pharyngeal infections usually heal under adequate therapy within a few days. Therefore severe regionary or systemic complications are not regularly seen. PATIENTS AND METHODS: We report on 3 patients in whom during or after apparent recovery from a pharyngeal or perioral infection a one-sided painful swelling of the neck associated with fever and leucocytosis developed. RESULTS: Color Doppler sonography (CDS) revealed unilateral thrombosis of the internal jugular vein (IJV) in all cases, whereupon we initiated high-dosed parenteral antibiotic therapy and therapeutic heparinisation. Furthermore, we drained detectable abscess formations. Nonetheless, in one patient fever attacks occurred postoperatively, accompanied by septic-embolic lung infiltrates, corresponding to Lemierre's syndrome. In all cases, we achieved clinical recovery and remission of infection. The course was significantly prolonged in the patient with pulmonary involvement and in this patient no reperfusion of the IJV was achieved. CONCLUSIONS: Even today serious complications may occur unexpectedly in presumed everyday oral or pharyngeal infections. CDS is a suitable procedure to disclose a jugular vein thrombosis (JVT) promptly and non-invasively. Parenteral antibiotic therapy for at least 10 days is usually the therapy of choice for JVT; additional full-heparinisation is controversially discussed in the professional literature. Septic pulmonary embolism following pharyngeal infection and JVT, as described by Lemierre, was associated with a high rate of mortality in the pre-antibiotic era, and even today may be fatal in spite of appropriate and maximal therapy.

A vanishing disease can still happen.

Lemierre's syndrome is a rare disease in the antibiotic era which is characterised by oropharyngitis, thrombophlebitis and septic metastases, but it can still occur and early recognition of its characteristic features and commencement of appropriate treatment can be life saving. The case history is described of a middle-aged man with Lemierre's syndrome who made an uneventful recovery following treatment with co-amoxiclav and metronidazole for 6 weeks.