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Chest Infections |

Lemierre's Syndrome: Forgiven, but Not Forgotten

Susan Mucha*, MD; Nicole Secca, MD; Kameron Ashker, MD; Marvin Balaan, MD; Tariq Cheema, MD
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Allegheny General Hospital, Pittsburgh, PA


Chest. 2012;142(4_MeetingAbstracts):177A. doi:10.1378/chest.1390664
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Abstract

SESSION TYPE: Infectious Disease Case Report Posters II

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Lemierre’s syndrome, or postanginal sepsis, begins with an oropharyngeal infection, progresses to septic thrombophlebitis of the internal jugular vein and septic metastasis. We present a young man with Lemierre’s syndrome complicated by respiratory failure.

CASE PRESENTATION: A 25-year-old healthy male presented to his PCP complaining of fevers, chills, sore throat, myalgias, and lymphadenopathy. Two days prior, he had kissed a woman with infectious mononucleosis. A work-up for EBV and streptococcal pharyngitis was negative. His symptoms progressed to nausea, emesis, cough, and weakness. While shopping a week later, EMS noted his profound weakness and brought him to his local hospital for dehydration. Blood cultures grew gram-negative rods later identified as Fusobacterium species. The patient was started on piperacillin-tazobactam and levofloxacin. A neck CT showed thrombosis involving the left internal jugular vein with extensive soft tissue changes along the left carotid sheath, contiguous with the left palatine tonsil. There was no abscess. A chest CT showed bilateral infiltrates suspicious for septic emboli. The patient was transferred to our MICU where he was emergently intubated for severe hypoxemia and worsening radiographic infiltrates. He had left neck tenderness and lymphadenopathy. The patient was treated with a regimen of piperacillin-tazobactam, clindamycin and intravenous heparin. He was extubated on ICU Day 7 and was discharged on Hospital Day 14 on amoxicillin-clavulanate for four more weeks and warfarin for three months.

DISCUSSION: This case describes Lemierre’s Syndrome that progressed to sepsis and respiratory failure. Andre Lemierre first published 20 cases in 1936, 18 patients died. The syndrome is a complication of an oropharyngeal infection, most commonly caused by Fusobacterium species. If left untreated, it can progress to internal jugular vein septic thrombophlebitis and septic pulmonary emboli. Prior to the advent of penicillin, mortality was approximately 90%. With the advent of penicillin, the incidence declined significantly to approximately 1 case per million per year, thus the syndrome became known as the “Forgotten Disease.” However, the incidence has increased over the last two decades. Mortality ranges from 5% - 15%. Treatment is directed at anaerobes, but should include coverage for potential co-infections. There are no controlled studies to support full anticoagulation, but is often recommended if response to antibiotics is poor. Abscess drainage or jugular vein ligation may be required.

CONCLUSIONS: Despite its rarity, Lemierre’s Syndrome should remain in the differential diagnosis in a young adult presenting with sore throat, fevers, and malaise.

1) Riordan T. Human infection with Fusobacterium necrophorum (Necrobacillosis) with a focus of Lemierre’s syndrome. Clin Microbiol Rev 2007; 20:622-59.

DISCLOSURE: The following authors have nothing to disclose: Susan Mucha, Nicole Secca, Kameron Ashker, Marvin Balaan, Tariq Cheema

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Allegheny General Hospital, Pittsburgh, PA

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