Lemierre’s syndrome: a case study with a short review of literature

Abstract

Objective and Importance Lemierre's syndrome (LS) is a rare condition that typically starts with a bacterial oropharyngeal infection complicated by a thrombophlebitis of the internal jugular vein and septic emboli to the lungs or other organs. The most common organism isolated is Fusobacterium necrophorum, although other causative organisms are isolated in rare cases. Case presentation We discuss a case of LS in a 44-year-old, previously healthy man presenting with an oropharyngeal infection. F. necrophorum was isolated from blood cultures and Computed tomography of the chest demonstrated septic emboli in the lungs. Magnetic resonance imaging showed a thrombophlebitis of the sigmoid and transverse vein with continuity to the internal jugular vein. Methods Case report and literature review. Results F. necrophorum isolates show in vitro susceptibility to metronidazole, clindamycin, beta-lactam/beta-lactamase inhibitor combinations and carbapenems with no signs of resistance or reduced sensitivity. Anticoagulation is believed to play a favourable role in recovery of the disease because of the potential for faster resolution of thrombophlebitis and bacteraemia. Conflicting results exist in literature with many studies or reviews indicating a favourable outcome both with and without anticoagulation. Anticoagulation for LS consists in most cases of Warfarin or Low molecular weight heparins, with the last being the first choice in children. Indications for the use of anticoagulation in literature are significant clot burden, complication of septic emboli, arterial ischemic stroke, poor response to antibiotics, thrombophilia and cerebral infarction. Conclusions Antibiotics are considered the mainstay of treatment, although statistically valid trials to evaluate optimal treatment regimens have not yet been conducted due to the low incidence of the infection. The use of anticoagulation in LS is still heavily debated as a result of conflicting results in literature. Due to the disease's low incidence, statistically valid trials that evaluate anticoagulation are lacking. Further prospective and randomized research is needed to establish the benefit of anticoagulation in the treatment of LS.

Lemierre’s Syndrome: A Thing of the Past?

“…This is consistent with other studies which have shown F. Necrophorum is most susceptible to antibiotics such as metronidazole, clindamycin, and beta-lactams due to good penetration and oral bioavailability. [3] , [14] Studies maintain that clinicians should begin treatment with broad-spectrum therapy with anerobic coverage. [15] Conversely, anticoagulative therapy was only used in 35 cases, half of the cases analyzed.…”

Síndrome de Lemierre. Caso y revisión de la literatura

“…Tanto la ligadura como la resección de la vena trombosada era una práctica habitual en la era preantibiótica. Hoy día no se utiliza o se reserva para los casos de sepsis no controlada con tratamiento convencional o persistencia de embolias sépticas a pesar de un adecuado tratamiento antibiótico (6,7,(10)(11)(12)(15)(16)(17) .…”

Septic emboli of the lung due to Fusobacterium necrophorum, a case of Lemierre's syndrome

“…It is still a rare syndrome with an estimated worldwide incidence of 1/1,000,000 [6]. F. necrophorum is a gram-negative, non-spore forming, anaerobic bacilli [1]. F. necrophorum is divided into two subspecies: F. necrophorum subsp.…”

“…It is not recommended in the absence of thrombus extension [9]. Anticoagulation should be considered on an individual basis with specialist teams involved if there is evidence of significant extension of thrombus, especially in the presence of persistent, progressive or refractory bacteremia or uncontrolled clinical sepsis [1,2].…”

“…Fusobacterium necrophorum (F. necrophorum), an anaerobe [1] has been detected in the oropharynx of asymptomatic healthy young adults [2]. Rates of detection are higher in symptomatic patients with acute pharyngitis and even higher in adults with recurrent pharyngitis [2].…”