Lemierre's syndrome: Difference between revisions
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*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> | ||
*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]] | *Usually affects young, healthy adults, most often developing after [[Strep Pharyngitis]] causing [[Peritonsilar Abscess|peritonsilar abscess]] | ||
**[[Anerobic Bacteria]] grow in the [[ | **[[Anerobic Bacteria]] grow in the [[Peritonsilar Abscess|peritonsilar abscess]] and penetrate into the neighboring jugular vein causing thrombophlebitis and bacteremia and septic emboli and occassionally [[pneumonia]] and [[sepsis]] | ||
===Epidemiology=== | ===Epidemiology=== | ||
Very rare, incidence rate of 0.8 cases per million in the general population<ref>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.</ref> | *Very rare, incidence rate of 0.8 cases per million in the general population<ref>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.</ref> | ||
*When diagnosed, mortality is 4.6%<ref>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</ref> | |||
== | ==Clinical Features== | ||
*Persistent sore throat, [[fever]], and general weakness | *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]] | ||
***[[Septic Arthritis]] | ***[[Septic Arthritis]] | ||
***[[Meningitis]] | ***[[Meningitis]] | ||
***[[Sepsis]] | ***[[Sepsis]] | ||
***Intracranial complications (6%) | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
* [[Q fever]] | *[[Q fever]] | ||
* [[Tuberculosis]] | *[[Tuberculosis]] | ||
* [[Pneumonia]] | *[[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]]) | |||
==Workup== | {{Sore throat DDX}} | ||
==Evaluation== | |||
===Workup=== | |||
[[File:Lemierre Kilpatrick.gif|thumbnail|POCUS shows IJ thrombus<ref>http://www.thepocusatlas.com/soft-tissue-vascular/</ref>]] | |||
*CTA of neck | *CTA of neck | ||
*Point of care [[ultrasound]] may reveal IJ thrombus | |||
*[[Blood Cultures]] | *[[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== | ==Management== | ||
*Antibiotics | *Antibiotics (coverage of [[F. necrophorum]], [[strep]], [[bacteroides]]) - [[Unasyn]], [[Zosyn]], or [[carbapenem]] for at least 3-4 wks | ||
**IV [[Antibiotics]] | **IV [[Antibiotics]] | ||
*Drainage of abscess | *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> | ||
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==Disposition== | ==Disposition== | ||
*Admit | *Admit | ||
==See Also== | ==See Also== | ||
*[[ | *[[Peritonsillar abscess]] | ||
*[[Sepsis]] | *[[Sepsis]] | ||
== | ==Video== | ||
{{#widget:YouTube|id=-UOjKNn-xqA}} | |||
==References== | |||
<references/> | <references/> | ||
[[Category:ID]] | |||
[[Category:ENT]] | |||
Revision as of 21:04, 30 September 2019
Background
- Also known as "Lemierre's disease" and "postanginal shock including sepsis" and "human necrobacillosis"
- Is a form of thrombophlebitis[1]
- 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
Workup
POCUS shows IJ thrombus[5]
- 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 (coverage of F. necrophorum, strep, bacteroides) - Unasyn, Zosyn, or carbapenem for at least 3-4 wks
- IV Antibiotics
- Drainage of abscess
- Consider ligation of the internal jugular vein where antibiotic can not penetrate.[6]
- No evidence for or against anticoagulation[7]
Disposition
- Admit
See Also
Video
{{#widget:YouTube|id=-UOjKNn-xqA}}
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.