For a very brief summary of Lemierre’s syndrome, thrombophlebitis of the of the internal jugular vein, please also review Thrombophlebitis Of The Internal Jugular Vein – “EM Quick Hits 8 Lemierre’s Syndrome From Emergency Medicine Cases
Posted on October 28, 2019 by Tom Wade MD
This post contains links to and and excerpts from Lemierre’s Syndrome: Recognising a Typical Presentation of a Rare Condition [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Case Rep Infect Dis. 2015;2015:797415. doi: 10.1155/2015/797415. Epub 2015 Jan 27.
The above article has been cited by 3 PubMed Central articles.
Lemierre’s syndrome is a rare complication following an acute oropharyngeal infection. The aetiological agent is typically anaerobic bacteria of the genus Fusobacterium. The syndrome is characterised by a primary oropharyngeal infection followed by metastatic spread and suppurative thrombophlebitis of the internal jugular vein. If left untreated, Lemierre’s syndrome carries a mortality rate of over 90%. Whilst relatively common in the preantibiotic era, the number of cases of Lemierre’s syndrome subsequently declined with the introduction of antibiotics. With the increase of antibiotic resistance and a greater reluctance to prescribe antibiotics for minor conditions such as tonsillitis, there are now concerns developing about the reemergence of the condition. This increasing prevalence in the face of an unfamiliarity of clinicians with the classical features of this “forgotten disease” may result in the misdiagnosis or delay in diagnosis of this potentially fatal illness. This case report illustrates the delay in diagnosis of probable Lemierre’s syndrome in a 17-year-old female, its diagnosis, and successful treatment which included the use of anticoagulation therapy. Whilst there was a positive outcome, the case highlights the need for a suspicion of this rare condition when presented with distinctive signs and symptoms.
Lemierre’s syndrome is caused by bacteria of the genus
Fusobacterium, most commonly F. necrophorum, but occasionally F. nucleatum, F. mortiferum, and F. varium [1–4]
[They] are normal flora of the gastrointestinal tract, oropharynx, and female urogenital tract [1, 5]. The pathogenesis of the disease remains unknown. . .
Once the invasion of the pharyngeal mucosa has
occurred, the proximity of the internal jugular vein allows
for further spread of the fusobacteria from the peritonsillar
space into this vessel [1, 2, 4]. Platelet aggregation and
subsequent thrombus formation in the internal jugular vein
are a direct consequence of this bacteraemia, and this also acts
a source of metastatic septic emboli [1, 4, 10].
Lemierre’s syndrome was common before the discovery
of antibiotics .With increased use of penicillin for bacterial
throat infections from the 1960s, the number of reports of
Lemierre’s syndrome dropped at this time [7, 12–14]. However, there is evidence to suggest that the incidence of this
disease is rising [2, 15, 16].
Despite such reports, Lemierre’ssyndrome remains a rare condition, with one retrospective study from Denmark estimating an incidence of around 1 case per million .
This case report highlights the challenge in the timely diagnosis of Lemierre’s syndrome.
2. Case Report
A 17-year-old female presented at the emergency department following a 7-day history of worsening sore throat,
fever, headache, and vomiting and a 4-day history of developing neck pain.
Her illness initially started with fever, headache, and sore throat with subsequent loss of appetite.
The headache was reported to fluctuate in severity and was
described more like a migraine, although it was relieved
slightly by paracetamol.
The sore throat was severe enough to affect her intake of food, as she was unable to swallow solids, but liquids were unaffected.
The patient reported vomiting following the onset of the illness, although this only initially occurred after eating and there was no blood or bile present. The vomiting subsided in the following days due to decreased intake of food. However, one more episode of vomiting occurred the day before admission which was reported to be bilious.
The patient had previously been seen by her general practitioner and at the emergency department on two previous occasions (four and three days before admission). She was discharged on all occasions with the diagnosis of a self-limiting viral illness.
Subsequently, she developed a leftsided neck pain, radiating down the lateral margin of her neck (ranked as 6/10 for severity) and was admitted to the emergency department via an ambulance.
Her temperature was 39.9∘ C, respiratory rate was 18
breaths/min, blood pressure was 105/44 mmHg, and heart
rate was 137 bpm.