View source for Lemierre's syndrome

==Background==
*Also known as "Lemierre's disease" and "postanginal shock including sepsis" and "human necrobacillosis"
*Is a form of [[thrombophlebitis]]<ref>"Lemierre syndrome" at Dorland's Medical Dictionary</ref> and defined by a history of recent oropharyngeal infection, clinical or radiological evidence of IJ venous thrombosis and anaerobic bacteremia caused primarily by [[Fusobacterium necrophorum]]
*Usually caused by ''[[Fusobacterium necrophorum]]'', and occasionally by other members of the genus ''Fusobacterium'' (''F. nucleatum, F. mortiferum and F. varium'' etc.) or [[MRSA]]
*Usually affects young, healthy adults, most often developing after [[Strep Pharyngitis]] causing [[Peritonsilar Abscess|peritonsilar abscess]]
**[[Anerobic Bacteria]] grow in the [[Peritonsilar Abscess|peritonsilar abscess]] and penetrate into the neighboring jugular vein causing thrombophlebitis and bacteremia and septic emboli and occassionally [[pneumonia]] and [[sepsis]]

===Epidemiology===
*Very rare, incidence rate of 0.8 cases per million in the general population<ref>Sibai K, Sarasin F (2004). "Lemierre syndrome: a diagnosis to keep in mind". Revue médicale de la Suisse romande (in French) 124 (11): 693–5. PMID 15631168.</ref>
*When diagnosed, mortality is 4.6%<ref>Centor RM. "Expand the Pharyngitis Paradigm for Adolescents and Young Adults." Ann Intern Med. 2009;151(11):812-815. doi:10.7326/0003-4819-151-11-200912010-00011</ref>

==Clinical Features==
[[File:PMC3663068 kjo-27-219-g002.png|thumb|Example of an intracranial complication: paresis of the abducens nerve (demonstrated in the right eye when looking to the right).]]
*Persistent [[sore throat]], [[fever]], and general [[weakness]]
*2 days - 2 weeks after initial symptoms:
**Lethargy, [[fevers]], [[lymphadenopathy]], [[neck pain|painful neck]]
**Often [[abdominal pain]], [[diarrhea]], [[nausea and vomiting]]
**May lead to:
***[[Pneumonia]]
***[[Septic Arthritis]]
***[[Meningitis]]
***[[Sepsis]]
***Intracranial complications (6%)

==Differential Diagnosis==
*[[Q fever]]
*[[Tuberculosis]]
*[[Pneumonia]]
*Viral [[pharyngitis]]
*[[Mononucleosis]]-like illnesses (EBV, CMV, acute HIV)
*[[Peritonsillar abscess]] vs. [[Retropharyngeal abscess]] vs. [[Ludwig's angina]]
*[[Mumps]]
*[[Sjögren Syndrome]]
*Heerfordt's syndrome (small percentage of [[sarcoidosis]])

{{Sore throat DDX}}

==Evaluation==
[[File:Lemierre Kilpatrick.gif|thumbnail|POCUS shows IJ thrombus<ref>http://www.thepocusatlas.com/soft-tissue-vascular/</ref>]]
[[File:PMC2813609 ASM-29-58-g001.png|thumb|CT of the neck showing partial thrombosis of the right internal jugular vein (black arrow) and complete thrombosis of the right external jugular vein (white arrow).]]
===Workup===
*CTA of neck
*Point of care [[ultrasound]] may reveal IJ thrombus
*[[Blood Cultures]]

===Evaluation===
Diagnostic criteria:
*History of oropharynx pain within last 4 wks
*Evidence of IJV thrombophlebitis/carotid sheath
*Isolation of F. necrophorum from blood
*Evidence of metastatic infection in another site (lungs)

==Management==
*Antibiotics (specifically anaerobic coverage of [[F. necrophorum]] PLUS [[strep]], AND [[bacteroides]])
**[[Unasyn]], [[Zosyn]], or [[carbapenem]] for at least 3-4 wks
*Drainage of [[abscess]]
*Consider ligation of the internal jugular vein where antibiotic can not penetrate.<ref>Chirinos JA, Lichtstein DM, Garcia J, Tamariz LJ (November 2002). "The evolution of Lemierre syndrome: report of 2 cases and review of the literature". Medicine (Baltimore) (Lippincott Williams & Wilkins) 81 (6): 458–465. doi:10.1097/00005792-200211000-00006. PMID 12441902.</ref>
*No evidence for or against anticoagulation<ref>Puymirat E, Biais M, Camou F, Lefèvre J, Guisset O, Gabinski C (March 2008). "A Lemierre's syndrome variant caused by Staphylococcus aureus". American journal of emergency medicine test (Elsevier) 26 (3): 380–387. doi:10.1016/j.ajem.2007.05.020. PMID 18358967.</ref><ref>Hoehn KS. Lemierre’s syndrome: the controversy of anticoagulation. Pediatrics. 2005;6(5):1415–1416.</ref>

==Disposition==
*Admit

==See Also==
*[[Peritonsillar abscess]]
*[[Sepsis]]

==Video==
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==References==
<references/>

[[Category:ID]]
[[Category:ENT]]