What is the diagnosis, management, and complications of Lemierre syndrome?

Lemierre Syndrome: Diagnosis, Management, and Complications

Lemierre syndrome requires prompt diagnosis and treatment with a prolonged course (3-6 weeks) of antibiotics with anaerobic coverage to prevent significant morbidity and mortality. 1

Clinical Presentation and Diagnosis

Typical Presentation

• Adolescents or young adults with:
  • Progressive symptoms following pharyngitis/tonsillitis
  • Persistent high fever and rigors
  • Night sweats
  • Tender cervical lymphadenopathy
  • Swelling along the sternocleidomastoid muscle
  • Neck pain or swelling
  • Symptoms of septic emboli (most commonly pulmonary)

High-Risk Clinical Patterns

• Prolonged symptoms of pharyngitis
• Pharyngitis that initially improves then worsens
• Critically ill patients with pharyngitis
• Pharyngitis with infection at a secondary site
• Neck signs/symptoms following oropharyngeal infection 2

Diagnostic Approach

1. Blood cultures - essential for isolating causative organism (typically Fusobacterium necrophorum)
2. Imaging studies:
   • CT scan of neck with IV contrast - to identify internal jugular vein thrombophlebitis
   • CT scan of chest with IV contrast - to identify pulmonary septic emboli
   • Additional imaging based on clinical suspicion of metastatic infections 1, 2

Management

Initial Stabilization

• Hemodynamic stabilization with IV fluids
• Vasopressors if needed for septic shock 2

Antibiotic Therapy

• First-line treatment: Prolonged course (3-6 weeks) of antibiotics with anaerobic coverage
  • Metronidazole plus β-lactam antibiotics (e.g., ampicillin-sulbactam, piperacillin-tazobactam)
  • Coverage should be broad initially until culture results return 1, 2

Anticoagulation

• Controversial aspect of management
• May be considered in cases with extensive thrombosis
• Decision should be made using a multidisciplinary approach
• No clear consensus on duration if initiated 1, 2, 3

Surgical Intervention

• Drainage of abscesses when present
• Ligation of the internal jugular vein may be necessary in severe cases with:
  • Persistent sepsis despite appropriate antibiotics
  • Recurrent septic emboli 1, 4

Complications

Metastatic Infections

• Pulmonary (most common):
  • Pneumonia
  • Pleural empyema
  • Cavitating lung lesions
• Neurological:
  • Brain abscesses
  • Meningitis
  • Cavernous sinus thrombosis
• Vascular:
  • Arterial thrombosis
  • Septic thrombophlebitis
• Other:
  • Septic arthritis
  • Osteomyelitis
  • Hepatic and splenic abscesses 1, 2, 5

Mortality and Morbidity

• Mortality rate: 4-12% with appropriate therapy
• Significantly higher mortality when diagnosis or therapy is delayed
• Substantial morbidity even with appropriate treatment 4

Monitoring and Follow-up

• Close monitoring for clinical improvement
• Follow-up imaging to assess resolution of thrombosis and metastatic lesions
• Extended antibiotic therapy until complete resolution of all infectious foci

Key Points for Clinicians

• Maintain high index of suspicion in young adults with severe pharyngitis and persistent neck pain
• Early diagnosis and prompt initiation of appropriate antibiotics are critical
• Consider Lemierre syndrome in patients with pharyngitis who deteriorate despite standard treatment
• Multidisciplinary management may be necessary for complicated cases

Lemierre syndrome remains a potentially life-threatening condition that requires rapid recognition and aggressive management to prevent serious complications and death.