Can Lemierre syndrome occur without fever?

Can Lemierre Syndrome Occur Without Fever?

While fever is the most common presenting symptom in Lemierre syndrome, occurring in the vast majority of cases, the absence of fever does not exclude the diagnosis, particularly in elderly patients, immunocompromised individuals, or those who have received prior antibiotic treatment.

Clinical Presentation of Lemierre Syndrome

Lemierre syndrome typically presents with a constellation of symptoms following oropharyngeal infection, with fever being the predominant feature:

• Patients most commonly present with fever, recently diagnosed pharyngitis, and neck pain or swelling 1
• The classic triad consists of pharyngotonsillitis, internal jugular vein thrombosis, and septic emboli resulting in metastatic abscess 1
• Common presenting symptoms include combinations of fever, pharyngitis, dysphagia, odynophagia, or oropharyngeal swelling 2
• Additional features include persistent fever, rigors, night sweats, tender lymph nodes, and swollen tonsils 3

When Fever May Be Absent

Critical caveat: Fever may be absent in specific patient populations, which is a well-recognized phenomenon in infectious diseases 4:

• Elderly patients may not mount a febrile response 4
• Immunocompromised patients may present without fever 4
• Patients who have received antibiotic pre-treatment may have blunted fever response 4
• Infections involving less virulent or atypical organisms may present without fever 4

Diagnostic Approach When Lemierre Syndrome Is Suspected

Clinicians should maintain a high index of suspicion for Lemierre syndrome in adolescent and young adult patients with severe pharyngitis, regardless of fever status 4, 3:

• Consider Lemierre syndrome in patients with prolonged symptoms of pharyngitis, pharyngitis that improves but then worsens, critically ill patients with pharyngitis, patients with pharyngitis and infection at a secondary site, and neck signs/symptoms 1
• Patients presenting with unusually severe signs and symptoms, such as difficulty swallowing, drooling, neck tenderness, or swelling, should be evaluated for rare throat infections including Lemierre syndrome 4

Essential Diagnostic Studies

When Lemierre syndrome is suspected, even without fever:

• Obtain throat and blood cultures 1
• Perform computed tomography of the neck and chest with intravenous contrast 1
• Additional imaging of other areas should be performed as clinically indicated for suspected septic emboli 1

Management Implications

The absence of fever should not delay diagnosis or treatment, as Lemierre syndrome is a life-threatening condition requiring urgent intervention 1, 5:

• Initial management includes hemodynamic stabilization with intravenous fluids and vasopressors as needed, as well as broad-spectrum antibiotics 1
• Prompt clinical diagnosis and treatment with appropriate antibiotics are critical 5
• The condition carries high rates of morbidity and mortality even with treatment 6

Clinical Pitfall to Avoid

The most dangerous pitfall is dismissing the possibility of Lemierre syndrome based solely on the absence of fever, particularly in elderly, immunocompromised, or antibiotic-pretreated patients 4. The syndrome can be easily missed in early phases, and given its potential severity, early recognition and expedient appropriate antimicrobial treatment are critical 2.