Lemierre’s syndrome (LS) is a suppurative infection caused by Fusobacterium necrophorum. Metastatic abscesses resulting from septic embolization secondary to internal jugular vein thrombophlebitis characterize this syndrome.
A 39-year-old black male presented to the Emergency Department with a five-day history of constipation, abdominal pain, high-grade fever and left leg swelling with pain. Past medical history was non-contributory except for dental work three weeks prior to admission.Initial vital signs were temperature 103F, heart rate 130/min, respiratory rate 26/min and a blood pressure of 126/75. Oropharynx was normal. Notable findings were icterus, abdominal tenderness and swelling in the left leg and left side of neck. Admission labs revealed a white blood cell count of 21,000/cu.mm, hemoglobin of 12.9g/dL, platelets of 59,000/cu.mm, bilirubin of 5.3mg/dL, alkaline phosphatase of 521IU, blood urea nitrogen of 68mg/dl and creatinine of 2.4mg/dL.A computerized tomogram (CT) scan of the abdomen revealed multiple abscesses in the liver and lung. A transesophageal echocardiogram was unremarkable. Blood cultures were positive for Fusobacterium necrophorum, and he was treated with imipenem and clindamycin. Ultrasound of the internal jugular vein revealed no thrombophlebitis. A CT scan of the left lower extremity revealed myositis.After four weeks of intravenous antibiotics he was discharged on oral amoxicillin/clavulanate.DISCUSSION: Lemierre’s syndrome is characterized by an acute oropharyngeal infection, suppurative thrombophlebitis of the internal jugular vein, anaerobic sepsis and metastatic abscesses. It was A. Lemierre in 1936 who described the syndrome in detail .Pulmonary involvement is reported in up to 85% of cases . Hepatic involvement may present as jaundice, abdominal pain and hepatomegaly with abscesses. Hyperbilirubinemia may be either due to hepatic abscesses or a direct effect of the toxin on the biliary tree . Joint and bone involvement may present as septic arthritis or osteomyelitis.Blood cultures may take several days to become positive, as in this case . Ultrasonography, CT scan, or magnetic resonance angiography of the neck can diagnose thrombosis of internal jugular vein. Ultrasonography was negative for thrombosis of the internal jugular vein in our patient. It is probable that the thrombus was present in an area relatively inaccessible to ultrasound, like the skull base, where the mandible inhibits full visualization or behind the clavicle .The recommended treatment of Lemierre’s syndrome is a combination of high dose penicillin and metronidazole or monotherapy with Clindamycin for 2-6 weeks .Drainage of abscesses is often necessary. Anticoagulation is controversial and carries the risk of extending the infection .
Lemierre’s Syndrome should be suspected in a young patient with antecedent oropharyngeal infection presenting with features of systemic septic embolization. Imaging of internal jugular vein helps in establishing a diagnosis. Early institution of appropriate antibiotics results in a favorable outcome.
M.T. Ali, None.