EDUCATIONAL PEARL

Lemierre syndrome: rare complication of bacterial pharyngitis/tonsillitis, involving septic thrombophlebitis of the internal jugular vein. 

• Presenting Symptoms: 

• Often preceded by pharyngitis. 

• Other preceding conditions include mastoiditis, otitis, dental infections, pharyngeal abscesses, or infectious mononucleosis.

• Clinical manifestations: fever, rigors, exudative tonsillitis, sore throat, dysphagia, trismus, unilateral neck pain, and tenderness, respiratory symptoms. 

• Signs of IJV thrombosis: neck tenderness, swelling, and/or induration over the neck, over the angle of the jaw, or along the SCM muscle. 

• Epidemiology: 

• Highest incidence occurred prior to the use of antibiotics. 

• After the introduction of penicillin, the incidence of LS has decreased dramatically. 

• It is now incredibly rare with a worldwide incidence rate of 1/1,000,000. 

• It typically affects young health adolescents and adults.  

• Etiology/Pathophysiology: 

• Begins with oropharyngeal infection. 

• Commonly caused by Fusobacterium necrophorum and Fusobacterium nucleatum. 

• F. necrophorum is part of the bacterial flora in the pharynx, GI, and female genital tract. 

• It is believed that conditions/environments that are conducive to F. necrophorum growth can lead to infection. 

• The infection can then spread from the oropharynx to the internal jugular vein. 

• At the IJV, septic thrombosis occurs because of intravascular coagulation, venous stasis, and intrinsic vessel osculation. 

• This leads to a systematic infection due to release of septic emboli.

• Diagnosis: 

• Diagnosis is primarily clinical.

• Further lab evaluation needed for patients presenting with concern for sepsis or with systemic inflammatory response syndrome (SIRS) criteria. 

• Blood cultures 

• 70% of cases show Fusobacterium species. 

• Chest radiograph to evaluate septic emboli and other pulmonary complications.

• Other imaging modalities used to evaluate functional or septic thrombosis of the IJV include:

• Ultrasound 

• CT of the neck with contrast MRI 

Treatment: Empiric antibiotic therapy: piperacillin-tazobactam, carbapenem, ceftriaxone. 

Lemierre syndrome: IJV Imaging