Lemierre Syndrome

Background

• Lemierre syndrome refers to suppurative thrombophlebitis of the jugular vein, most often arising as a complication of head and neck infections.
• Pharyngitis is the most common preceding infection but other infections such as otitis media, dental infections, and infectious mononucleosis are also reported.
• Disease is most often due to Fusobacterium necrophorum, an anaerobic gram-negative rod, but infections with other oropharyngeal bacteria can be causative.
• Symptoms related to the development of septic thrombophlebitis typically arise about 4-5 days following the initial inciting infection.
  • Fever, chills, and rigors are the most common symptoms.
  • Additional symptoms, occurring in about 20%-30% of patients, include sore throat, erythema, and swelling or tenderness under the angle of the jaw.
  • Respiratory distress may be present in those with septic emboli to the lung, which is reported to occur in up to 85% of patients.

Evaluation

• Consider the diagnosis of Lemierre syndrome in patients with persistent or worsening sore throat, fever, and rigors with or without unilateral neck pain and swelling after resolution of pharyngitis or other head and neck infection.
• Physical examination findings may be absent or subtle but include pharyngeal or tonsillar inflammation. Neck swelling and tenderness are variably present. The thrombosed vein is rarely palpable.
• Respiratory signs or symptoms may indicate septic emboli to the lung.
• Perform blood cultures when considering the diagnosis of Lemierre syndrome. Note that anaerobic bacteria may take longer to grow in a culture than aerobes.
• Computed tomography (CT) with contrast of the neck is generally the preferred imaging modality when assessing for internal jugular vein thrombophlebitis.
• Ultrasound may also be used but is less sensitive and does not allow for evaluation below the clavicle.
• For detection of septic emboli to the lung or other organs, CT can be used, but magnetic resonance imaging (MRI) may also be useful because it has better soft tissue contrast than CT.

Management

• Treatment usually requires antibiotics and, less commonly surgical intervention.
• Definitive antibiotic therapy should be individualized based on detected pathogen(s) and susceptibility profile.
• Commonly used antibiotic regimens with activity against fusobacteria include:
  • ampicillin-sulbactam 3 g IV every 6 hours OR
  • piperacillin-tazobactam 3.375 g IV every 6 hours OR
  • penicillin 2-4 million units IV every 4 to 6 hours plus metronidazole 500mg IV every 6 to 8 hours
• The optimal duration of therapy has not been determined but consider 4-6 weeks of an appropriate IV agent.
• Surgery may be considered for patients who fail to respond to antibiotics alone or for those with complicating abscesses requiring drainage.
• Use of anticoagulation for the prevention of embolization of thrombus is controversial and is not generally recommended.