Lemierre’s Syndrome

Carrying along with the theme of unusual conditions presenting as the common illnesses (see also Kawasaki Disease, HUS and many other Pediatric conditions), let’s bring to mind Lemierre’s Syndrome.

• Jugular Vein Thrombosis (JVT) associated with an anaerobic infection in the neck and often complicated by septic pulmonary emboli. So that sore throat with chest pain may be strep throat, or it may be Lemierre’s Syndrome.

• JVT may arise from infection of the lateral pharyngeal space (tonsillitis, pharyngitis, mastoiditis, odontogenic abscess). Also can be complication of direct trauma (popsicle stick stuck into posterior pharynx).

• The infection and host factors influence the development of the JVT. One study demonstrated that a thrombophilia is often present (100% of their cases had some form of thrombophilia – small sample size and possible selection bias though).

• This was a significant entity in the Pre-Antibiotic Era, but now seems to re-emerging as a important clinical entity… particularly in children and young adults.

• Many different pathogens have been associated with “Lemierre’s Like-Syndrome” (Strep, Staph, M. Catarrhalis, Mucor) but the term “Lemierre’s Syndrome” is traditionally reserved for those caused by Fusobacterium necrophorum (but that is still debated by those who like semantics).

• Consider this diagnosis when the patient has Neck Pain (83%), Dyspnea (50%), is worsening (usually day 3-4), has evidence of thrombophlebitis in the neck, or has pharyngitis not improving on antibiotics.

• Treatment consists of Antibiotics (IV Clindamycin and Metronidazole initially, then tailored based on cultures) AND Anticoagulants.

Historic Interest: Lemierre did not discover the organism, nor did he first describe the condition: his clarified the overall presentation and course. He also boldly stated:
“To anyone instructed as to the nature of these septicemias it becomes relatively easy to make a diagnosis on the simple clinical findings. The appearance and repetition several days after the onset of a sore throat (and particularly of a tonsillar abscess) of severe pyrexial attacks with an initial rigor or still more certainly the occurrence of pulmonary infarcts and arthritic manifestations, constitute a syndrome so characteristic that mistake is almost impossible.”
I wish I could be so definitive.

Goldenberg, NA, Knapp-Clevenger, R, Hays, T, and Manco-Johnson, MJ. Lemierre’s and Lemierre’s-Like Syndromes in Children: Survival and Thromboembolic Outcomes. Pediatrics 2005;116:e543–e548.

Riordan, T. Human Infection with Fusobacterium necrophorum (Necrobacillosis), with a Focus on Lemierre’s Syndrome. Clinical Microbiology Reviews Oct. 2007; p.622-659.

Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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