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Lemierre Syndrome

Necrobacillosis


Presentation

  • By presenting our cases we demonstrate the diverse presentations and severity of the illness. A review of the literature and a case report on two cases seen in our institution in the last year are presented.[ncbi.nlm.nih.gov]
  • We report a case of a previously healthy 33-year-old male who presented to his primary care physician with nausea, vomiting, diarrhoea and fever.[ncbi.nlm.nih.gov]
  • To present a unique case of multilevel vertebral osteomyelitis after Lemierre syndrome.[ncbi.nlm.nih.gov]
  • We present a case of invasive Fusobacterium infection that meets all criteria for Lemierre syndrome except lacking internal jugular thrombosis.[ncbi.nlm.nih.gov]
  • We present 3 cases within a 12-month period of young, family practice patients seen with oropharyngeal infections who developed Lemierre syndrome.[ncbi.nlm.nih.gov]
Fatigue
  • A common 1- to 2-week history of fever, sore throat, neck pain, and fatigue was observed in all patients. Patient 1 developed right facial swelling, neck tenderness, trismus, and tonsillar exudate.[ncbi.nlm.nih.gov]
  • Unlike many who suffer from the disease, Iniguez was diagnosed with Lemierre's Syndrome, a rare and deadly disease that often goes overlooked by physicians because it presents with such basic symptoms, such as fever, shortness of breath and fatigue.[petaluma360.com]
  • Symptoms associated with sepsis include: fever above 101 F shortness of breath dizziness mental confusion increased heart rate chills fatigue Symptoms of advanced sepsis include: difficulty breathing hallucinations incoherent speech irregular heartbeats[medicalnewstoday.com]
Infectious Mononucleosis
  • Postanginal sepsis following infectious mononucleosis. Arch Intern Med. 1987 Sep; 147 (9):1581–1583. [ PubMed ] [ Google Scholar ] Busch N, Mertens PR, Schönfelder T, Nguyen H, Marschall HU, Kierdorf H, Haase G, Urhahn R, Sieberth HG, Matern S.[ncbi.nlm.nih.gov]
  • Several cases of Lemierre's syndrome preceded by infectious mononucleosis have been reported, 11 12 so that some authors have suggested the possible role of primary viral throat infection as a risk factor for the syndrome. 3 Enhancement of toxins from[pmj.bmj.com]
  • Monospot: a differential slide test for infectious mononucleosis J Clin Pathol [online] 1969 May, 22(3):324-325 [viewed 25 December 2014] Available from: 19. CARTER PK, SCHOEN I, MIYAHIRA T.[clinicalsenseapp.com]
  • The differential diagnosis of Lemierre's syndrome is vast and includes viral pharyngitis, infectious mononucleosis, acute retroviral syndrome, leptospirosis, acute bacterial pneumonia, atypical pneumonia, aspiration pneumonia, infective endocarditis,[casesjournal.biomedcentral.com]
  • The differential diagnosis of Lemierre syndrome includes infectious mononucleosis, parapharyngeal abscess, pneumonia and other conditions causing septic emboli, such as endocarditis. 6 Management Successful management of a complex condition, such as Lemierre[jcda.ca]
Streptococcal Pharyngitis
  • Recent evidence (3, 4) suggests that Fusobacterium necrophorum pharyngitis occurs as often as streptococcal pharyngitis in patients aged 15 to 30 years.[annals.org]
  • However its incidence fell dramatically with the introduction of antibiotics for the treatment of streptococcal pharyngitis. Since the advent of antibiotic therapy Lemierre’s syndrome was thought to be the forgotten disease.[ommegaonline.org]
  • Diagnosis and treatment of streptococcal pharyngitis. Am Fam Physician [online] 2009 Mar 1, 79(5):383-90 [viewed 09 January 2015] Available from: 2.[clinicalsenseapp.com]
Death in Childhood
  • This case demonstrates yet another infectious condition that may be associated with rapid deterioration and unexpected death in childhood. An autopsy approach to suspected sepsis in childhood is outlined.[ncbi.nlm.nih.gov]
  • Lemierre syndrome and unexpected death in childhood. Increased diagnosis of Lemierre syndrome and other Fusobacterium necrophorum infections at a children's hospital," Pediatrics, vol.[medical-dictionary.thefreedictionary.com]
Intravenous Administration
  • Prolonged intravenous administration of antimicrobial agents known to have a good antianaerobic coverage, along with drainage of purulent collections, will usually be successful in the overwhelming majority of patients.[ncbi.nlm.nih.gov]
Nausea
  • We report a case of a previously healthy 33-year-old male who presented to his primary care physician with nausea, vomiting, diarrhoea and fever.[ncbi.nlm.nih.gov]
  • Gastrointestinal complaints such as abdominal pain, nausea, and vomiting were common (49.5% of cases). An elevated white blood cell count occurred in 75.2% of cases.[ncbi.nlm.nih.gov]
  • Often there is abdominal pain, diarrhea, nausea and vomiting during this phase. These signs and symptoms usually occur several days to 2 weeks after the initial symptoms.[en.wikipedia.org]
  • As the disease progresses, additional symptoms may include: nausea, loss of appetite, diarrhea, or vomiting coughing or pain while breathing chills severe headaches dental pain pain, swelling, and stiffness of the joints, such as knees or hips yellowish[medicalnewstoday.com]
Pericardial Friction Rub
  • friction rubs as a sign of pericarditis (rare) * Cranial nerve paralysis and Horner\'s syndrome (both rare) Causes - Lemierre's syndrome Not supplied.[checkorphan.org]
  • friction rubs as a sign of pericarditis (rare) Cranial nerve paralysis and Horner's syndrome (both rare) The bacteria causing the thrombophlebitis are anaerobic bacteria that are typically normal components of the microorganisms that inhabit the mouth[en.wikipedia.org]
Joint Effusion
  • He developed left-sided complicated otitis media with retroauricular fluid collection, mastoiditis, and temporomandibular joint effusion. The clinical picture was complicated by a left internal jugular vein and left lateral sinus thrombosis.[ncbi.nlm.nih.gov]
Oligoarthritis
  • Postma, A 25-year-old male with oligoarthritis as the first sign of Lemierre’s syndrome, Infection, 10.1007/s15010-010-0071-7, 39, 1, (87-89), (2011).[doi.org]
Chemosis
  • A 54-year-old woman presented with fever, spasmodic torticollis, ptosis, and chemosis in her left eye.[ncbi.nlm.nih.gov]
  • An 86-year-old patient was hospitalized for fever and left acute orbital syndrome (red eye with moderate visual impairment, chemosis, ophthalmoplegia without proptosis, or any fundus involvement).[ncbi.nlm.nih.gov]
Blepharoptosis
  • A 51-year-old woman was hospitalized with a high fever, occipital pain, blepharoptosis, and trismus.[ncbi.nlm.nih.gov]
  • Megu Yamaguchi, Hitoshi Nishizawa, Taku Yasumoto, Takekazu Kimura, Yasuo Takeuchi, Akinori Takeshita, Toshiyuki Takase, Hiroaki Fujimoto, Misa Nakano and Megumu Fukunaga, Lemierre Syndrome with Blepharoptosis, Internal Medicine, 10.2169/internalmedicine[doi.org]
Visual Impairment
  • An 86-year-old patient was hospitalized for fever and left acute orbital syndrome (red eye with moderate visual impairment, chemosis, ophthalmoplegia without proptosis, or any fundus involvement).[ncbi.nlm.nih.gov]
Red Eye
  • An 86-year-old patient was hospitalized for fever and left acute orbital syndrome (red eye with moderate visual impairment, chemosis, ophthalmoplegia without proptosis, or any fundus involvement).[ncbi.nlm.nih.gov]
Neck Swelling
  • A 10-year-old boy is reported who had a five-day history of ear infection, with the development of fever, drowsiness and ipsilateral neck swelling. Unexpected cardiac arrest occurred soon after medical assessment.[ncbi.nlm.nih.gov]
  • Finally, pediatricians, internists, family physicians, and emergency department physicians should know the red flags for adolescent and young adult pharyngitis: worsening symptoms or neck swelling (especially unilateral neck swelling).[ncbi.nlm.nih.gov]
  • Neck swelling may be evident. Bacteremia and distal infective thromboembolism is common (lungs most commonly affected, however almost any organ may be involved 4 ).[radiopaedia.org]
  • The 2 major red flags in adolescent and young adult pharyngitis are worsening symptoms or neck swelling. If the patient has bacteremic symptoms, treat either with a combination of penicillin and metronidazole or with clindamycin alone.[annals.org]
Facial Swelling
  • Patient 1 developed right facial swelling, neck tenderness, trismus, and tonsillar exudate. Patient 2 displayed right tonsillar erythema and enlargement with right neck tenderness.[ncbi.nlm.nih.gov]
  • General examination showed right sided facial swelling and tenderness along the right sided sternocleidomastoid. Oral examination revealed inflammation of right tonsillar fossa.[ijcasereportsandimages.com]
Cellulitis of the Face
  • We report the case of a 22-year-old woman hospitalized initially for cellulitis of the face.[ncbi.nlm.nih.gov]
Kidney Failure
  • After infection starts to set in, symptoms worsen and include: High fever Rigors (chills and shivering) Swollen lymph nodes in the neck Joint pain Complications can lead to: Lung abscess Brain abscess Kidney failure Septic shock Acute respiratory distress[clicks.co.za]
  • failure Liver failure Abscesses in the spleen Pockets of infection in the muscle and skin Meningitis Brain abscesses Diagnosis Lemierre's syndrome is diagnosed through blood tests that identify the bacteria causing the observed symptoms.[everydayhealth.com]
Headache
  • A 76-year-old Japanese male presenting with high fever, headache, and disturbance of consciousness was hospitalized.[ncbi.nlm.nih.gov]
  • Some cases will also present with meningitis, which will typically manifest as neck stiffness, headache and sensitivity of the eyes to light.[en.wikipedia.org]
  • The latter usually appears with nonspecific symptoms, the most common being frontal headache. 4 The culture was positive for S. viridans . Thrombosis/occlusion of the internal carotid artery is a very rare complication.[elsevier.es]
  • CASE REPORT A 34-year-old housewife presented with a short history of fever, and headache for 20 days; odynophagia, neck pain, right sided facial swelling for 10 days; and hemoptysis for five days.[ijcasereportsandimages.com]
  • This is a very rare disease with only approximately 160 cases in the last 100 years.[1] Symptoms - Lemierre's syndrome * Headache (not related to meningitis) * Muscle pain * Jaundice * Trismus * Crepitations are sometimes heard over the lungs * Pericardial[checkorphan.org]
Lethargy
  • Lethargy and respiratory distress were noted. Based on radiographic findings of bilateral infiltrates he was diagnosed with pneumonia and started on intravenous ampicillin and erythromycin.[ncbi.nlm.nih.gov]
  • SYMPTOMS: Severe Sore Throat Extreme Lethargy Fever General Body Weakness Shortness of Breath Chest Pain Pneumonia & Strep Throat like symptoms After the infection starts to set in (could be a week or two) the symptoms become worst & include: Spiked HIGH[lemierresyndrome.com]
  • These are followed by extreme lethargy, spiked fevers, rigors, swollen cervical lymph nodes, and a swollen, tender or painful neck. Often there is abdominal pain, diarrhea, nausea and vomiting during this phase.[en.wikipedia.org]
Polyneuropathy
  • Each of these had varied presentations and neurologic complications-one developed 9th to 12th cranial nerve palsies and Horner syndrome, which have not been described in previous literature, and the other developed polyneuropathy and a frontal lobe infarct[ncbi.nlm.nih.gov]
  • Each of these had varied presentations and neurologic complications—one developed 9th to 12th cranial nerve palsies and Horner syndrome, which have not been described in previous literature, and the other developed polyneuropathy and a frontal lobe infarct[doi.org]
Cranial Neuropathy
  • Abstract Lemierre syndrome is usually caused by Fusobacterium necrophorum, but we recently encountered a case due to methicillin-resistant Staphylococcus aureus and complicated by sigmoid sinus thrombosis and cranial neuropathies.[ncbi.nlm.nih.gov]
Tonic-Clonic Seizure
  • Her hospital course was complicated by a middle cerebral artery distribution infarction and subsequent hemorrhagic conversion with generalized tonic clonic seizures managed by levetiracetam.[ncbi.nlm.nih.gov]

Workup

  • A high index of suspicion is needed to consider this diagnosis in the workup of pharyngitis and should be aggressively treated once identified.[ncbi.nlm.nih.gov]
  • Lemierre syndrome is a condition that can have high morbidity and mortality, but if it is diagnosed early in a patient's workup, that is, in the ED, the morbidity and mortality can be significantly decreased.[ncbi.nlm.nih.gov]
  • Further imaging workup was then arranged to identify any potential source of the septic emboli but echocardiogram did not reveal any heart valve vegetation. Figure 2.[hkmj.org]
  • Bearing in mind, the clinical suspicion of Lemierre’s syndrome, patients presenting with pharyngitis and associated high grade fevers, should undergo a careful and thorough examination of the neck and blood cultures as part of the initial workup.[omicsonline.org]
Pericardial Effusion
  • Two-dimensional-echo revealed circumferential pericardial effusion with mild pericardial thickening and moderate tricuspid regurgitation. Cardiolipin antibodies were within normal limits. d-Dimer assay and C reactive protein were markedly raised.[ncbi.nlm.nih.gov]
  • Ten days into her hospital stay, she developed pericardial tamponade, and cardiac surgery performed a pericardial window for loculated, purulent pericardial effusion.[ncbi.nlm.nih.gov]

Treatment

  • Treatment with broad-spectrum antibiotics is the primary choice of treatment of Lemierre syndrome. Surgery is indicated in case of abscess formation.[ncbi.nlm.nih.gov]
  • Treatment with endoscopic sphenoidotomy, culture-directed antibiotics, heparinization, and endovascular GDC coiling were performed and the patient recovered without major neurologic morbidity.[ncbi.nlm.nih.gov]
  • Early diagnosis and prolonged appropriate antibiotic treatment with good anaerobic coverage are crucial to reduce morbidity and mortality.[ncbi.nlm.nih.gov]
  • His clinical condition improved gradually and after 3 weeks of intravenous antibiotics he was discharged home on oral treatment.[ncbi.nlm.nih.gov]
  • Optimal treatment outcome with reduced or absence of sequelae can be achieved with early diagnosis.[ncbi.nlm.nih.gov]

Prognosis

  • Even without internal jugular thrombosis, the same mechanism of disease exists, and therefore, the same morbidity, prognosis, and treatments are applicable, hence the suitable term incomplete Lemierre syndrome.[ncbi.nlm.nih.gov]
  • Immediate and intensive treatment with careful evaluation to localize the primary infectious focus of the head and neck, including the paranasal sinus, improves the prognosis of patients with rhinogenic Lemierre syndrome.[ncbi.nlm.nih.gov]
  • If unrecognised and untreated, systemic dissemination can occur with a dismal prognosis; studies from the modern era still report mortality rates as high as 18% 8.[radiopaedia.org]
  • If unrecognised and untreated, systemic dissemination can occur with a dismal prognosis; studies from the modern era still report mortality rates as high as 18% 8 .[radiopaedia.org]
  • This review aims to provide physicians with an update on the etiology, management, and prognosis of Lemierre's syndrome.[ncbi.nlm.nih.gov]

Etiology

  • In 81% of the cases, the Fusobacterium necrophorum is the most frequent etiologic agent. Fever is the most common symptom, but it can depending on the primary infection, tonsillitis, mastoiditis or odontogenic infection.[ncbi.nlm.nih.gov]
  • This report will provide readers with a better understanding of the etiology, clinical presentation, evaluation methods, and appropriate treatment of LS.[ncbi.nlm.nih.gov]
  • The etiologic agent is not always an anaerobic bacterium.[ncbi.nlm.nih.gov]
  • Fusobacterium necrophorum is the usual etiologic agent. The disease progresses in several steps. The first stage is the primary infection, which is usually a pharyngitis (87.1% of cases).[ncbi.nlm.nih.gov]

Epidemiology

  • Further epidemiologic research is needed on both F. necrophorum pharyngitis (especially clinical presentation) and the Lemierre syndrome. Clinicians need reliable diagnostic techniques for F. necrophorum pharyngitis.[ncbi.nlm.nih.gov]
  • Incidence and clinical epidemiology of necrobacillosis, including Lemierre's syndrome, in Denmark 1990–1995. Eur J Clin Microbiol Infect Dis . 1998;17:561–5. ... 2. Chirinos JA, Lichtstein DM, Garcia J, Tamariz LJ.[aafp.org]
  • HagelskjaerKristensen L, Prag J.Lemierre’s syndrome and other disseminated Fusobacteriumnecrophorum infections in Denmark: a prospective epidemiological and clinical survey.Eur JClinMicrobiol Infect Dis. 2008; 27: 779–89.[nzma.org.nz]
  • PubMed Google Scholar Hagelskjaer LH, Prag J, et al: Incidence and clinical epidemiology of necrobacillosis in Denmark 1990-1995. Eur J Clin Microbiol Infect Dis. 1998, 17: 561-565. 10.1007/BF01708619.[casesjournal.biomedcentral.com]
  • Epidemiology : Although extremely rare now, Lemierre’s syndrome was common prior to the age of penicillins.[emdocs.net]
Sex distribution
Age distribution

Pathophysiology

  • The underlying pathophysiology and treatment options are discussed here. With rapid increase in reporting of Lemierre syndrome, this case deserves particular attention from clinicians.[ncbi.nlm.nih.gov]
  • The pathophysiology, natural history, diagnostic methods for internal jugular vein thrombosis, and management are discussed.[ncbi.nlm.nih.gov]
  • S.aureus) PATHOPHYSIOLOGY Primary infection is followed by local invasion of the lateral pharyngeal space then septic thrombophlebitis of the IJ vein primary source of infection is commonly the palatine tonsils and peritonsillar tissue other sources include[lifeinthefastlane.com]
  • Other isolates recovered alone or in combination include pigmented Prevotella , Bacteroides spp. and Peptostreptococcus spp. 6-8 Pathophysiology The source of the infection is pharyngitis, exudative tonsillitis, peritonsillar abscess or oral procedure[tonsilitisunderstood.blogspot.com]

Prevention

  • Early diagnosis and treatment of anaerobic pharyngitis is critical to prevent Lemierre Syndrome. Respiratory precautions should be recommended to medical staff caring for patients with suspected Lemierre Syndrome to prevent nosocomial transmission.[ncbi.nlm.nih.gov]
  • However, given the mortality rate of approximately 2%, prompt diagnosis and detection of septic emboli are essential to initiate prompt treatment, preventing organ damage and ongoing sepsis.[ncbi.nlm.nih.gov]
  • This condition can have significant morbidity and mortality; therefore, although it is not common in today's era of antimicrobials, it should still be considered and thought of to prevent the significant consequences that may occur from it.[ncbi.nlm.nih.gov]
  • This case illustrates the importance of diagnosing Lemierre syndrome in the presence of pharyngitis with localised neck pain and respiratory distress, to prevent potentially fatal complications.[ncbi.nlm.nih.gov]

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