Lemierre's Syndrome in Children: High-Resolution CT and Color Doppler Sonography Patterns

doi:10.1378/chest.112.1.271

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Volume 112, Issue 1, July 1997, Pages 271-273

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Lemierre's syndrome is an anaerobic sepsis occurring after oropharyngeal infection in healthy teenagers and young adults. We report two cases of adolescent girls suffering from Lemierre's syndrome studied with cervical color Doppler ultrasonography (CDUS), cervicothoracic helical CT, and high-resolution CT (HRCT) scanning. In both patients, HRCT allowed a good depiction of multiple cavitated pulmonary nodules of various sizes suggestive of this entity and was able to detect small or peripheral nodules. CDUS helped to pinpoint the extent of thromboses of the internal jugular vein demonstrated by CT. CDUS and HRCT should be performed as early as possible to confirm and treat this life-threatening condition.

Section snippets

Case Reports

Two girls, 15 and 17 years old, were admitted to the hospital with fever, pain, and swelling of the ipsilateral laterocervical region following pharyngotonsillar inflammation and moderate dyspnea. Laboratory analysis on admission showed a nonspecific inflammatory reaction with leukocytosis, elevated C-reactive protein and erythrocyte sedimentation rate. Blood cultures were positive for Fusobacterium necrophorum in one patient and weakly positive in the other who received broad-spectrum

Discussion

Lemierre's syndrome is a tonsillitis or peritonsillar abscess followed, when untreated, by a rapidly progressing septicemia and death.¹ Multisystem involvement of Lemierre's syndrome may suggest meningitis, septic arthritis, and intra-abdominal sepsis. Swelling of the submaxillary glands associated with tenderness of the sternocleidomastoid muscle is caused by thrombophlebitis of an internal jugular vein due to the anaerobic, nonmotile Gram-negative bacillus F necrophorum. The most frequent

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There are more references available in the full text version of this article.

Cited by (56)

Lemierre syndrome complicating otitis externa: Case report and literature review
2012, Journal of Emergency Medicine
Citation Excerpt :
Ultrasound, venography, CT scan, and magnetic resonance imaging (MRI) have been used for initial diagnosis. In the acute setting, contrast-enhanced CT scan of the neck may be the optimal test, due to its lack of invasiveness (as opposed to venography), availability (as opposed to MRI), and ability to identify the extent of propagation of the thrombus, allowing more optimal operative planning (as opposed to duplex ultrasound) (7,8). CT demonstrates a dilatated IJV and low-attenuation intraluminal content and enhancement of the vessel wall and surrounding tissue (9).
Background: Septic thrombophlebitis of the internal jugular vein, known as Lemierre syndrome, is a rare disorder usually caused by Fusobacterium necrophorum, a Gram-negative anaerobic organism that normally inhabits the oropharynx. Lemierre syndrome usually follows primary oropharyngeal infections and affects previously healthy adolescents and young adults in a characteristic manner, often with fatal results if left untreated. There have been a significantly increasing number of reported cases of Lemierre syndrome, possibly reflecting the trend to withhold antibiotics for initially uncomplicated oropharyngeal infections. Objectives: We hope to alert the reader to a potentially fatal disease process that has recently been increasingly identified, by reporting a unique manifestation of Lemierre syndrome, and by reviewing the current literature. Case Report: A 19-year-old woman presented to our Emergency Department with a chief complaint of fever, ear pain, and generalized weakness. She was noted to be in septic shock, with left neck erythema and swelling. A computed tomography scan showed thrombosis of the left internal jugular vein (IJV), which was later excised. She recovered after a course of intravenous and oral antibiotics. Conclusion: Septic thrombophlebitis of the IJV is associated with multiple sources and organisms. This case is unique in both the organism (Peptococcus anaerobius) and the source (otitis externa). This disease process must be identified early and aggressively treated to avoid significant morbidity and mortality.
Diagnosis of lemierre syndrome by bedside emergency department ultrasound
2010, Journal of Emergency Medicine
Citation Excerpt :
CT scan has the ability to identify discrete abscess or to determine the extent of thrombus; however, this information only sporadically changes the management of patients who are suspected of having Lemierre syndrome (2,5). Ultrasound also has been suggested as an initial method of diagnostic imaging (3,5,11–15). Although none of the recommendations for using ultrasound to diagnose Lemierre syndrome come from the Emergency Medicine literature, many of these cases initially present to the ED.
Oropharyngeal infections such as pharyngitis and odontogenic abscess are routinely encountered in emergency and primary care medical practice. Lemierre syndrome is a rare but serious complication of such infections. This syndrome is characterized by penetration of the primary infection into the lateral pharyngeal space, suppurative thrombophlebitis of the internal jugular vein, and metastatic infections resulting from septic emboli. A combination of clinical suspicion, microbiologic identification of the causative organism, and diagnostic imaging may be required to make the diagnosis. We present a case of Lemierre syndrome that was rapidly diagnosed in the Emergency Department with bedside ultrasound of the internal jugular vein. This case suggests that bedside ultrasound, performed before other radiologic imaging, may lead to earlier diagnosis and treatment of this syndrome, which historically has been associated with significant morbidity and mortality.
Lemierre syndrome
2010, Presse Medicale
Le syndrome de Lemierre est un état septique rare et grave à point de départ céphalique, associant une thrombose de la veine jugulaire interne et des emboles septiques, notamment pulmonaires.
Fusobacterium necrophorum est la bactérie qui en est principalement responsable.
Assez fréquente et souvent fatale à l’ère pré-antibiotique, cette affection est devenue extrêmement rare avant de connaître une recrudescence ces dernières années.
La guérison est la règle, souvent au prix d’une lente rémission et parfois d’un complément chirurgical.
Face à la ré-émergence de cette maladie infectieuse, une mise à jour des aspects épidémiologiques, diagnostiques et thérapeutiques s’impose.
Lemierre's syndrome is a rare and severe condition, with a primary focus in the cervicofacial area and followed by thrombosis of the internal jugular vein and metastatic infections, most often pulmonary.
The principal pathogen is Fusobacterium necrophorum.
Less rare and associated with high mortality before antibiotics, Lemierre syndrome had became exceptional until the increase in the number of cases in recent years.
Recovery is usually the rule, but often only after long convalescence and often surgical intervention.
The reemergence of this disease calls for a review of the literature to update knowledge about its epidemiologic, clinical, and therapeutic aspects.
Lemierre's syndrome [1]
2007, Anales de Pediatria
Human infections with Fusobacterium necrophorum
2006, Anaerobe
Fusobacterium necrophorum is a Gram-negative anaerobic bacillus that can be a primary pathogen causing either localised abscesses and throat infections or systemic life-threatening disease. Systemic infections due to F. necrophorum are referred to as either Lemierre's disease/syndrome, post-anginal sepsis or necrobacillosis, but in the context of this mini-review, all are included under the umbrella term of ‘invasive F. necrophorum disease’ (IFND). Although IFND has been well documented for over a century, it is quite a rare condition and modern-day clinicians of various medical disciplines are frequently unaware of this organism and the severity of symptoms that it can cause. IFND classically occurs in previously healthy young people although the factors that trigger the invasive process are not fully understood. There are countless descriptive case histories and small series of cases of IFND disease in the literature and although commonly referred to as a ‘forgotten’ disease, in truth, it is probably best described as a repeatedly ‘discovered’ disease, as it may not always be included in medical curricula, and neither is it mentioned in some major medical textbooks. There is some evidence that IFND may be on the increase, particularly in the UK. The potential reasons for this are considered in this review along with an historical overview, and updates on disease incidence, patient demography, pathogenesis and laboratory diagnosis.
Lemierre's syndrome: More judicious antibiotic prescribing habits may lead to the clinical reappearance of this often forgotten disease [3]
2006, American Journal of Medicine

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Case Reports

Discussion

References (9)

On certain septicemias due to anaerobic organisms

Lancet

Anaerobic infections (second of three parts)

N Engl J Med

Lemierre's disease: postanginal bacteremia and pulmonary involvement caused by Fusobacterium necrophorum

Rev Infect Dis

The Lemierre syndrome: suppurative thrombophlebitis secondary to oropharyngeal infection

Medicine

Cited by (56)

Lemierre syndrome complicating otitis externa: Case report and literature review

Diagnosis of lemierre syndrome by bedside emergency department ultrasound

Lemierre syndrome

Lemierre's syndrome [1]

Human infections with Fusobacterium necrophorum

Lemierre's syndrome: More judicious antibiotic prescribing habits may lead to the clinical reappearance of this often forgotten disease [3]

Chest

Special Reports: ArticlesLemierre's Syndrome in Children: High-Resolution CT and Color Doppler Sonography Patterns

Section snippets

Case Reports

Discussion

Lancet

Anaerobic infections (second of three parts)

N Engl J Med

Lemierre's disease: postanginal bacteremia and pulmonary involvement caused by Fusobacterium necrophorum

Rev Infect Dis

The Lemierre syndrome: suppurative thrombophlebitis secondary to oropharyngeal infection

Medicine

Special Reports: Articles
Lemierre's Syndrome in Children: High-Resolution CT and Color Doppler Sonography Patterns