Lemierre’s Syndrome

Hey #IDfellows, with Lemierre’s in mind, consider this case:

24M c/o fevers and facial swelling, found to have MSSA bacteremia and bil periorbital cellulitis.

CT chest shows septic pulm emboli but TEE neg for veg 🤔

The plot thickens….

He was persistently bacteremic.

Due to unrelenting neck pain, CT neck was done on day 7, which revealed a nonocclusive thrombus in R jugular vein. He denied sore throat or other pharyngeal symptoms

Does this case qualify as Lemierre’s syndrome?

This case fits the definition of Lemierre’s syndrome with jugular vein thrombosis and pulm emboli without endocarditis, but as was discussed before, usual culprit 🦠 are F. necrophorum (80%), other anaerobes and oral Strep species #spacedrepetition

So MSSA, what gives?

think tom hanks GIF by The Late Show With Stephen Colbert

We know Staph aureus has coagulase, which means…what?

Coagulase activates prothrombin, inducing coagulation

Staph also manipulates multiple other steps of the coagulation cascade

(Image from http://pubmed.ncbi.nlm.nih.gov/29251820)
And yes, the diagram *will* be on the test 😂

Multiple cases of S. aureus-associated Lemierre's syndrome have been reported in recent years

This recent case series includes 25 such patients:

http://pubmed.ncbi.nlm.nih.gov/31749395/

The case series is notable for several reasons:

Almost 50% had *no* pharyngeal symptoms, but had other head/neck infections such as orbital cellulitis. Patients were a wider age range than is typical for classic Lemierre’s, and 7 were <7yo. All were reported after 2002

The authors proposed that “Lemierre syndrome” should strictly refer to

1️⃣ jugular vein thrombosis with bacteremia

2️⃣ caused by anaerobes

3️⃣ due to pharyngeal infection and the term “Lemierre-like syndrome” for cases without pharyngeal infection or not caused by a typical anaerobe

Matthew Mcconaughey Ok GIF

Staph aureus is an emerging cause of jugular thrombosis with bacteremia and metastatic infection and may be due to sources other than the pharynx

This should be referred to as "Lemierre-like syndrome"

Thanks for playing! #IDTwitter #IdMedEd

Originally tweeted by Infectious Diseases Fellows Network (@ID_fellows) on 13 August, 2020.

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