Lemierre's syndrome: Difference between revisions
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==Background== | ==Background== | ||
*Also known as "Lemierre's disease" and "postanginal shock including sepsis" and "human necrobacillosis" | *Also known as "Lemierre's disease" and "postanginal shock including sepsis" and "human necrobacillosis" | ||
*Is a form of [[thrombophlebitis]]<ref>"Lemierre syndrome" at Dorland's Medical Dictionary</ref> | *Is a form of [[thrombophlebitis]]<ref>"Lemierre syndrome" at Dorland's Medical Dictionary</ref> and defined by a history of recent oropharyngeal infection, clinical or radiological evidence of IJ venous thrombosis and anaerobic bacteremia caused primarily by [[Fusobacterium necrophorum]] | ||
*Usually caused by ''[[Fusobacterium necrophorum]]'', and occasionally by other members of the genus ''Fusobacterium'' (''F. nucleatum, F. mortiferum and F. varium'' etc.) or [[MRSA]] | *Usually caused by ''[[Fusobacterium necrophorum]]'', and occasionally by other members of the genus ''Fusobacterium'' (''F. nucleatum, F. mortiferum and F. varium'' etc.) or [[MRSA]] | ||
*Usually affects young, healthy adults, most often developing after [[Strep Pharyngitis]] causing [[Peritonsilar Abscess|peritonsilar abscess]] | *Usually affects young, healthy adults, most often developing after [[Strep Pharyngitis]] causing [[Peritonsilar Abscess|peritonsilar abscess]] | ||
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==Clinical Features== | ==Clinical Features== | ||
*Persistent sore throat, [[fever]], and general weakness | [[File:PMC3663068 kjo-27-219-g002.png|thumb|Example of an intracranial complication: paresis of the abducens nerve (demonstrated in the right eye when looking to the right).]] | ||
*Persistent [[sore throat]], [[fever]], and general [[weakness]] | |||
*2 days - 2 weeks after initial symptoms: | *2 days - 2 weeks after initial symptoms: | ||
** | **Lethargy, [[fevers]], [[lymphadenopathy]], [[neck pain|painful neck]] | ||
**Often abdominal pain, [[diarrhea]], [[nausea and vomiting]] | **Often [[abdominal pain]], [[diarrhea]], [[nausea and vomiting]] | ||
**May lead to: | **May lead to: | ||
***[[Pneumonia]] | ***[[Pneumonia]] | ||
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
* [[Q fever]] | *[[Q fever]] | ||
* [[Tuberculosis]] | *[[Tuberculosis]] | ||
* [[Pneumonia]] | *[[Pneumonia]] | ||
* Viral pharyngitis | *Viral [[pharyngitis]] | ||
* Mononucleosis-like illnesses (EBV, CMV, acute HIV) | *[[Mononucleosis]]-like illnesses (EBV, CMV, acute HIV) | ||
* | *[[Peritonsillar abscess]] vs. [[Retropharyngeal abscess]] vs. [[Ludwig's angina]] | ||
* Mumps | *[[Mumps]] | ||
* | *[[Sjögren Syndrome]] | ||
* Heerfordt's syndrome (small percentage of sarcoidosis) | *Heerfordt's syndrome (small percentage of [[sarcoidosis]]) | ||
{{Sore throat DDX}} | {{Sore throat DDX}} | ||
== | ==Evaluation== | ||
[[File:Lemierre Kilpatrick.gif|thumbnail|POCUS shows IJ thrombus<ref>http://www.thepocusatlas.com/soft-tissue-vascular/</ref>]] | |||
[[File:PMC2813609 ASM-29-58-g001.png|thumb|CT of the neck showing partial thrombosis of the right internal jugular vein (black arrow) and complete thrombosis of the right external jugular vein (white arrow).]] | |||
===Workup=== | ===Workup=== | ||
*CTA of neck | *CTA of neck | ||
*Point of care | *Point of care [[ultrasound]] may reveal IJ thrombus | ||
*[[Blood Cultures]] | *[[Blood Cultures]] | ||
===Evaluation=== | ===Evaluation=== | ||
Diagnostic criteria: | |||
* | *History of oropharynx pain within last 4 wks | ||
*Evidence of IJV thrombophlebitis/carotid sheath | |||
*Isolation of F. necrophorum from blood | |||
*Evidence of metastatic infection in another site (lungs) | |||
==Management== | ==Management== | ||
*Antibiotics (coverage of F. necrophorum | *Antibiotics (specifically anaerobic coverage of [[F. necrophorum]] PLUS [[strep]], AND [[bacteroides]]) | ||
* | **[[Unasyn]], [[Zosyn]], or [[carbapenem]] for at least 3-4 wks | ||
*Drainage of [[abscess]] | |||
*Consider ligation of the internal jugular vein where antibiotic can not penetrate.<ref>Chirinos JA, Lichtstein DM, Garcia J, Tamariz LJ (November 2002). "The evolution of Lemierre syndrome: report of 2 cases and review of the literature". Medicine (Baltimore) (Lippincott Williams & Wilkins) 81 (6): 458–465. doi:10.1097/00005792-200211000-00006. PMID 12441902.</ref> | *Consider ligation of the internal jugular vein where antibiotic can not penetrate.<ref>Chirinos JA, Lichtstein DM, Garcia J, Tamariz LJ (November 2002). "The evolution of Lemierre syndrome: report of 2 cases and review of the literature". Medicine (Baltimore) (Lippincott Williams & Wilkins) 81 (6): 458–465. doi:10.1097/00005792-200211000-00006. PMID 12441902.</ref> | ||
*No evidence for or against anticoagulation<ref>Puymirat E, Biais M, Camou F, Lefèvre J, Guisset O, Gabinski C (March 2008). "A Lemierre's syndrome variant caused by Staphylococcus aureus". American journal of emergency medicine test (Elsevier) 26 (3): 380–387. doi:10.1016/j.ajem.2007.05.020. PMID 18358967.</ref> | *No evidence for or against anticoagulation<ref>Puymirat E, Biais M, Camou F, Lefèvre J, Guisset O, Gabinski C (March 2008). "A Lemierre's syndrome variant caused by Staphylococcus aureus". American journal of emergency medicine test (Elsevier) 26 (3): 380–387. doi:10.1016/j.ajem.2007.05.020. PMID 18358967.</ref><ref>Hoehn KS. Lemierre’s syndrome: the controversy of anticoagulation. Pediatrics. 2005;6(5):1415–1416.</ref> | ||
==Disposition== | ==Disposition== | ||
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==See Also== | ==See Also== | ||
*[[ | *[[Peritonsillar abscess]] | ||
*[[Sepsis]] | *[[Sepsis]] | ||
==References== | ==References== | ||
Latest revision as of 20:12, 17 April 2024
Background
- Also known as "Lemierre's disease" and "postanginal shock including sepsis" and "human necrobacillosis"
- Is a form of thrombophlebitis[1] and defined by a history of recent oropharyngeal infection, clinical or radiological evidence of IJ venous thrombosis and anaerobic bacteremia caused primarily by Fusobacterium necrophorum
- Usually caused by Fusobacterium necrophorum, and occasionally by other members of the genus Fusobacterium (F. nucleatum, F. mortiferum and F. varium etc.) or MRSA
- Usually affects young, healthy adults, most often developing after Strep Pharyngitis causing peritonsilar abscess
- Anerobic Bacteria grow in the peritonsilar abscess and penetrate into the neighboring jugular vein causing thrombophlebitis and bacteremia and septic emboli and occassionally pneumonia and sepsis
Epidemiology
- Very rare, incidence rate of 0.8 cases per million in the general population[2]
- When diagnosed, mortality is 4.6%[3]
Clinical Features
- Persistent sore throat, fever, and general weakness
- 2 days - 2 weeks after initial symptoms:
- Lethargy, fevers, lymphadenopathy, painful neck
- Often abdominal pain, diarrhea, nausea and vomiting
- May lead to:
- Pneumonia
- Septic Arthritis
- Meningitis
- Sepsis
- Intracranial complications (6%)
Differential Diagnosis
- Q fever
- Tuberculosis
- Pneumonia
- Viral pharyngitis
- Mononucleosis-like illnesses (EBV, CMV, acute HIV)
- Peritonsillar abscess vs. Retropharyngeal abscess vs. Ludwig's angina
- Mumps
- Sjögren Syndrome
- Heerfordt's syndrome (small percentage of sarcoidosis)
Acute Sore Throat
Bacterial infections
- Streptococcal pharyngitis (Strep Throat)
- Neisseria gonorrhoeae
- Diphtheria (C. diptheriae)
- Bacterial Tracheitis
Viral infections
- Infectious mononucleosis (EBV)
- Patients with peritonsillar abscess have a 20% incidence of mononucleosis [4]
- Laryngitis
- Acute Bronchitis
- Rhinovirus
- Coronavirus
- Adenovirus
- Herpesvirus
- Influenza virus
- Coxsackie virus
- HIV (Acute Retroviral Syndrome)
Noninfectious
Other
- Deep neck space infection
- Peritonsillar Abscess (PTA)
- Epiglottitis
- Kawasaki disease
- Penetrating injury
- Caustic ingestion
- Lemierre's syndrome
- Peritonsillar cellulitis
- Lymphoma
- Internal carotid artery aneurysm
- Oral Thrush
- Parotitis
- Post-tonsillectomy hemorrhage
- Vincent's angina
- Acute necrotizing ulcerative gingivitis
Evaluation
POCUS shows IJ thrombus[5]
Workup
- CTA of neck
- Point of care ultrasound may reveal IJ thrombus
- Blood Cultures
Evaluation
Diagnostic criteria:
- History of oropharynx pain within last 4 wks
- Evidence of IJV thrombophlebitis/carotid sheath
- Isolation of F. necrophorum from blood
- Evidence of metastatic infection in another site (lungs)
Management
- Antibiotics (specifically anaerobic coverage of F. necrophorum PLUS strep, AND bacteroides)
- Unasyn, Zosyn, or carbapenem for at least 3-4 wks
- Drainage of abscess
- Consider ligation of the internal jugular vein where antibiotic can not penetrate.[6]
- No evidence for or against anticoagulation[7][8]
Disposition
- Admit
See Also
References
- ↑ "Lemierre syndrome" at Dorland's Medical Dictionary
- ↑ Sibai K, Sarasin F (2004). "Lemierre syndrome: a diagnosis to keep in mind". Revue médicale de la Suisse romande (in French) 124 (11): 693–5. PMID 15631168.
- ↑ Centor RM. "Expand the Pharyngitis Paradigm for Adolescents and Young Adults." Ann Intern Med. 2009;151(11):812-815. doi:10.7326/0003-4819-151-11-200912010-00011
- ↑ Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
- ↑ http://www.thepocusatlas.com/soft-tissue-vascular/
- ↑ Chirinos JA, Lichtstein DM, Garcia J, Tamariz LJ (November 2002). "The evolution of Lemierre syndrome: report of 2 cases and review of the literature". Medicine (Baltimore) (Lippincott Williams & Wilkins) 81 (6): 458–465. doi:10.1097/00005792-200211000-00006. PMID 12441902.
- ↑ Puymirat E, Biais M, Camou F, Lefèvre J, Guisset O, Gabinski C (March 2008). "A Lemierre's syndrome variant caused by Staphylococcus aureus". American journal of emergency medicine test (Elsevier) 26 (3): 380–387. doi:10.1016/j.ajem.2007.05.020. PMID 18358967.
- ↑ Hoehn KS. Lemierre’s syndrome: the controversy of anticoagulation. Pediatrics. 2005;6(5):1415–1416.