A Lemierre-like syndrome caused by Staphylococcus aureus: an emerging disease.

Despite its clear definition, Lemierre's syndrome is frequently used to describe any septic thrombophlebitis of the jugular vein. We report a Lemierre-like syndrome caused by Staphylococcus aureus without an oropharyngeal infection and present a systematic synthesis of reported cases to date of Lemierre-like syndrome caused by S. aureus. In addition to our case, 24 cases were found. In contrast to the classical picture, S. aureus is associated with an oropharyngeal infection in less than half of the cases. Another striking feature is the significant proportion of patients being very young and the fact that all 25 cases were published in the last 17 years. S. aureus is a rare, but emerging cause of Lemierre-like syndrome. Adequate patient care rests on a high index of suspicion, prompt initiation of antibiotic therapy and early detection and management of metastatic abscesses.BULLET POINT SUMMARYThe term Lemierre's syndrome should be reserved for the classic triad of bacteraemia caused by anaerobic pathogens (primarily Fusobacterium necrophorum), evidence of internal jugular venous thrombosis, and a history of recent oropharyngeal infection.Similar syndromes not caused by anaerobic organisms or without history of an oropharyngeal infection should be named Lemierre-like syndrome and may be a more challenging diagnosis.Staphylococcus aureus is a cause of Lemierre-like syndrome, especially in very young children (<2 years old).The Staphylococcus aureus Lemierre-like syndrome is an emerging clinical syndrome.Adequate patient care is based on a high index of suspicion, prompt initiation of broad-spectrum antibiotics and active detection and management of metastatic abscesses.

Interobserver agreement for the bedside clinical assessment of suspected stroke.

BACKGROUND AND PURPOSE: Stroke remains primarily a clinical diagnosis, with information obtained from history and examination determining further management. We aimed to measure inter-rater reliability for the clinical assessment of stroke, with emphasis on items of history, timing of symptom onset, and diagnosis of stroke or mimic. We explored reasons for poor reliability. METHODS: The study was based in an urban hospital with an acute stroke unit. Pairs of observers independently assessed suspected stroke patients. Findings from history, neurological examination, and the diagnosis of stroke or mimic, were recorded on a standard form. Reliability was measured by the kappa statistic. We assessed the impact of observer experience and confidence, time of assessment, and patient-related factors of age, confusion, and aphasia on inter-rater reliability. RESULTS: Ninety-eight patients were recruited. Most items of the history and the diagnosis of stroke were found to have moderate to good inter-rater reliability. There was agreement for the hour and minute of symptom onset in only 45% of cases. Observer experience and confidence improved reliability; patient-related factors of confusion and aphasia made the assessment more difficult. There was a trend for worse inter-rater reliability among patients assessed very early and very late after symptom onset. CONCLUSIONS: Clinicians should be aware that inter-rater reliability of the clinical assessment is affected by a variety of factors and is improved by experience and confidence. Our findings have implications for training of doctors who assess patients with suspected stroke and identifies the more reliable components of the clinical assessment.