Our case highlights some of the most commonly reported findings in Lemierre syndrome in addition to some specific features previously unreported in our review of the subject.
Our patient's sore throat had all but resolved by the time he presented to clinic. His primary complaints at presentation were vomiting, diarrhoea and fever. It is important to note that gastrointestinal complaints such as nausea, vomiting, diarrhoea and abdominal pain are common (49.5%) in Lemierre syndrome,4
and may be the presenting symptoms. Given the self-limited nature of the pharyngitis, it is the responsibility of the physician to elicit a history of oropharnygeal infection which can be found in 82–100% of the cases.3 5
Spread of Fusobacterium
into the lateral pharyngeal space via direct or lymphangitic spread ultimately leads to neck vein thrombosis. Contrast enhanced neck CT is the reported best imaging modality to evaluate for thrombosis. Ultrasound and MRI are also effective, but have limitations.6
Our case also highlights the role of other Fusobacterium
species in Lemierre syndrome. F necrophorum
is most commonly reported and accounts for 81% of the reported cases. F varium
and other species account for 11% of infections.7
Any blood cultures revealing Fusobacterium
should prompt the suspicion of Lemierre syndrome.
An almost invariable and critical characteristic of Lemierre syndrome is pulmonary septic embolisation (79–100% of cases).5 6 8 9
Non-cavitary pulmonary infiltrates are the reported most common finding on initial chest radiography. As in our case, cavitary lesions and evidence of septic embolisation are usually revealed soon after admission on CT.
Although the role of antibiotic therapy is well established, the role of anticoagulation in the treatment of Lemierre syndrome remains a controversial topic. Reports range from no anticoagulation therapy to treatment with 6 months of warfarin.9
There are no controlled studies evaluating the use of anticoagulation. Support for treatment is based on the idea that anticoagulation speeds resolution of the source of septic emboli and hastens recovery. It is therefore reasonable to begin anticoagulation therapy if there is evidence of thrombus propagation or embolic events.5 10
The length of anticoagulation should be based on clinical judgment weighing therapeutic response against the bleeding risks of therapy.
- Lemierre syndrome is a rare condition which begins as an often self-limited oropharyngeal infection but evolves into a life-threatening form of sepsis.
- Some 50% of patients present with gastrointestinal symptoms, however pharyngeal symptoms may not be apparent and must be elicited by the physician.
- Septic embolisation in an otherwise healthy young patient or blood cultures revealing Fusobacterium species should suggest the diagnosis.
- Antibiotic therapy for a period of 3–6 weeks is recommended.
- Anticoagulation remains controversial, but has been recommended when there is evidence of thrombus propagation or septic embolisation.