Lemierre’s syndrome

Hey #IDFellows, here is a new #IDTwitter Tweetorial

24F w/1 wk hx pharyngitis + 1d cough & SOB. VS T 39.3C, RR 23, SpO2 92%, HR 112. Exam with tonsillar swelling & erythema; L neck pain and swelling on palpation. CXR w/peripheral nodular opacities. Best empiric abx?

Lemierre’s syndrome = #eponym for suppurative thrombophlebitis of the jugular vein. Often preceded by pharyngitis +/- neck swelling. Commonly associated with pulmonary septic emboli. Check these #NEJM Clinical Images:

Most common organisms include Fusobacterium necrophorum >>> other fusobacterium > anaerobic streptococci. Fusobacterium necrophorum, an anaerobic gram-negative rod, seems to be distinctively adept at causing septic thrombophlebitis.

Affected patients are younger, teens to 30s, with preceding pharyngeal inflammation (such as mononucleosis or other viral illness). Some cases have followed documented influenza virus infection. See discussion by @WuidQ about pharyngitis:

The suspected mechanism of pathogenesis is tonsillitis vs peritonsillar abscess with localized extension; can involve the carotid sheath. Anaerobic bacteria cause inflammation and thrombus (septic thrombophlebitis). This can lead to septic emboli (in lungs and joints).

Severe complications involve erosion of carotid artery, cephalic extension of the clot, or cranial nerve involvement. Here is a great example of the #anatomy anatomy of Lemierre’s using #ultrasound ultrasound:

For Leimerre’s syndrome, incl anaerobic coverage. F necrophorum typically susceptible to PCN – but they may contain beta-lactamases. Amox/Clav, Pip/Tazo, Flagyl and Clinda often active. In a critically ill patient with unclear syndrome, covering more broadly is recommended.

Treatment is often prolonged, requiring weeks of antibiotics as the clot resolves. The role of anticoagulation is unclear and frequently clinician dependent.

F. necrophorum has been implicated in septic thrombophlebitis in other regions of the body, including the pelvic vasculature in women and the portal venous system. Excellent Review:

https://pubmed.ncbi.nlm.nih.gov/17934077/

Summary:
Lemierre’s syndrome = Septic Thrombophlebitis.
➡️Syndrome of pharyngitis +/- neck pain + fever + septic emboli.
➡️Empiric tx should cover anaerobic gram negatives and streptococci.
➡️The syndrome is most frequently associated with Fusobacterium necrophorum.

#IDFellows can check out other #IDTwitter resources here:
https://twitter.com/medrants/status/1218185603558211584
https://twitter.com/WuidQ/status/1060304207411138561
https://twitter.com/MayoClinicINFD/status/1165729419048161280
https://blogs.jwatch.org/hiv-id-observations/index.php/fusobacterium-pharyngitis-and-the-limits-of-limiting-antibiotics/2015/02/21/

Originally tweeted by Infectious Diseases Fellows Network (@ID_fellows) on 12 August, 2020.

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