Lemierre syndrome variant: necrobacillosis associated with inferior vena cava thrombosis and pulmonary abscesses after trauma-induced leg abscess

Fusobacterium necrophorum, a rarely encountered but potentially lethal bacterial pathogen, is the cause of Lemierre syndrome, an oropharyngeal infection complicated by jugular vein thrombophlebitis and metastatic septic embolization. We describe an unusual variant of this disease in a man who developed F necrophorum sepsis (associated with extensive inferior vena cava and common femoral vein thrombosis) and multiple abscesses in the lungs after a trauma-associated abscess of the left lower extremity. We highlight the predilection of F necrophorum to cause a potentially fatal septic illness irrespective of its primary focus and emphasize the importance of this bacterium as a cause of considerable morbidity.     

Lemierre's syndrome following infectious mononucleosis

We report the case of an 18-year-old woman who was admitted to the medical intensive care unit in Innsbruck with severe septic shock and respiratory insufficiency following a prolonged infection of the upper airways (pharyngitis, sinusitis). Abscessing pneumonia and bilateral pleural empyema were diagnosed as focus. Cultures of pleural fluids were positive for Fusobacterium necrophorum. In addition to multiple organ dysfunction syndrome (acute lung injury, acute renal failure, disseminated intravascular coagulation), she developed tenderness in the right neck followed by septic arthritis of the right sternoclavicular joint a few days later. Further history revealed a previous period of infectious mononucleosis (EBV infection). The previously healthy patient eventually made a complete recovery after prolonged treatment in the ICU including antibiotic therapy and multiple surgical interventions and drainage. Lemierre's syndrome is characterized by severe infection, with pharyngitis, sepsis and thrombosis of the internal jugular vein, and is most frequently associated with upper airway infection with Fusobacterium necrophorum, often preceded by infection with Epstein-Barr virus which enables bacteria growing in the oral cavity to invade.     

Necrobacillosis in humans

Necrobacillosis, often used synonymously with Lemierre's syndrome, is a form of abscess infection in the peritonsillar area associated with a thrombophlebitis and caused by the strict anaerobic species Fusobacterium necrophorum. The thrombosis formed affects the internal jugular vein, from which the bacteria are seeded out in the bloodstream and cause bacteremia. Septicemia is a common complication with an often fatal outcome. Necrobacillosis is very rare and is referred to as the 'forgotten disease'. It is probably frequently overlooked in clinical practice in its early and milder forms such as tonsillitis (sore throat) and peritonsillar abscess. F. necrophorum frequently participates in these infections and is thus suspected to have an etiological role in Lemierre's syndrome. Similarly, F. necrophorum seems to play an important role in noma (cancrum oris) and this disease is also included in the necrobacillosis complex. Diagnosis of infections of the necrobacillosis complex seeks to disclose F. necrophorum in swab samples or blood culture. The most commonly used therapy is metronidazole in combination with penicillin or amoxicillin. Clindamycin is also an option, especially in cases of penicillin allergy.     

Lemierre syndrome: a Japanese patient returning from Thailand

After returning from Thailand, a 23-year-old Japanese man was admitted because of fever, sore throat, neck pain, and chest pain. Contrasted-enhanced CT scanning of his neck revealed an absence of flow through the right internal jugular vein representing thrombosis, and moreover, an increase in wall thickness of the right internal jugular vein and enhancement of the surrounding tissue representing thrombophlebitis. Lung abscesses were also identified by a chest CT scan. Fusobacterium nucleatum was cultured in bronchoalveolar lavage fluid. He was diagnosed with Lemierre syndrome, and a good result was obtained by the administration of antibiotics. Physicians are encouraged to be aware of this syndrome when they manage patients complaining of neck pain and fever.     

Lemierre syndrome

ABSTRACT: Lemierre's syndrome is an uncommon complication of pharyngitis in the United States and caused most commonly by the bacterium Fusobacterium necrophorum. The syndrome is characterized by a history of recent pharyngitis followed by ipsilateral internal jugular vein thrombosis and metastatic pulmonary abscesses and is a disease for which patients will seek medical care and advice. As most patients are admitted to the hospital under internal medicine, practitioners should be familiar with the usual signs and symptoms of Lemierre's syndrome along with its diagnosis and treatment. Controversy involves the choice and duration of antimicrobial therapy used for treatment and anticoagulation therapy for internal jugular vein thrombosis. As the diagnosis and management of this syndrome has generated controversy, an updated review of the literature and treatment recommendations may be helpful for providing optimal care for patients with this often unrecognized and confusing infection.     

Lemierre Syndrome: Often Overlooked

Lemierre syndrome is an uncommon, emergent medical condition that is characterized by suppurative thrombophlebitis of the internal jugular vein, usually after a bacterial oropharyngeal infection. Although the incidence had nearly disappeared since the advent of antibiotics, there has been a resurgence of the diagnosis. Fusobacterium necrophorum is the most common causative pathogen, although others have been associated. Lemierre syndrome must be identified early and treated appropriately to reduce patient morbidity and mortality. The nurse practitioner should consider this diagnosis in all young, previously healthy patients who present with worsening sore throat and fever despite treatment with antibiotics.     

Lemierre syndrome

Lemierre syndrome is a disease that presents with oropharyngeal infection, sepsis, internal jugular vein thrombosis, and septic emboli with the Gram-negative organism Fusobacterium necrophorum cultured as the etiologic agent. Clindamycin, metronidazole and ampicillin-sulbactam are effective antibiotic treatments, although the length of treatment has not been firmly established. The syndrome is seen less frequently in the current age of antibiotics. It is important, however, that physicians be aware of the syndrome as initiation of prompt antibiotic therapy, including anaerobic coverage, is essential for avoiding morbidity and mortality. We describe a case of Lemierre syndrome.     

Lemierre syndrome complicating a subcutaneous neck abscess

Lemierre syndrome is septic thrombophlebitis of the internal jugular vein caused typically by an oropharyngeal infection. We report a case of Lemierre syndrome complicating a subcutaneous neck abscess. Lemierre syndrome should be considered in the differential diagnosis of septic emboli and sepsis, especially in a patient with tenderness along the sternomastoid muscle.     

Fusobacterium necrophorum endocarditis Case report and review of the literature

Fusobacterium necrophorum is a gram-negative anaerobic bacillus that can cause serious systemic infections typically in previously healthy young adults. Lemierre's syndrome, also known as post-anginal sepsis or necrobacillosis, is the infection most usually associated with F. necrophorum. However, F. necrophorum is also a very rare cause of anaerobic endocarditis. Mortality and rates of thromboembolism are high with F. necrophorum endocarditis. In this article, we describe a case of F. necrophorum native valve infective endocarditis. The patient was treated with penicillin plus clindamycin followed by penicillin alone for 6 weeks resulting in complete resolution of infection.     

Rapid identification of Fusobacterium nucleatum and Fusobacterium necrophorum by fluorescence in situ hybridization

Identification of clinically relevant Fusobacterium spp. is hampered by their slow growth, their frequent occurrence in polymicrobial culture, and the low reliability of biochemical differentiation methods. A newly developed fluorescence in situ hybridization (FISH) assay allowed reliable and rapid identification of Fusobacterium necrophorum and Fusobacterium nucleatum from culture. Preliminary results show that the method offers the perspective for direct detection of these pathogens in blood cultures and abscess aspirates.     

Lemierre's syndrome: an unusual cause of sepsis and abdominal pain

OBJECTIVE: To describe a patient with Lemierre's syndrome who presented with acute abdominal findings and to describe the evaluation and treatment of this syndrome. DESIGN: Case report. SETTING: A 38-bed, pediatric intensive care unit at a tertiary care children's hospital. PATIENT: One patient presenting with signs of severe sepsis and acute abdominal pain. INTERVENTIONS: Intravenous hydration, inotropic support, thoracostomy tube drainage of a pleural effusion, and prolonged antimicrobial therapy. MEASUREMENT AND MAIN RESULTS: The patient presented with severe sepsis and abdominal pain. After Fusobacterium necrophorum grew in blood cultures, anaerobic antimicrobial therapy was initiated. Doppler duplex ultrasonography and magnetic resonance venography demonstrated thrombus formation in the left internal jugular vein. Computed tomography of the chest demonstrated bibasilar lung nodules consistent with septic emboli. The patient was treated with ampicillin-sulbactam and metronidazole intravenously for 3 wks, followed by a 3-wk course of oral amoxicillin/clavulanate. He had a good recovery, and his thrombus had resolved at the time of discharge. CONCLUSION: Lemierre's syndrome occurs in young, otherwise healthy patients, and it thus needs to remain high on the differential diagnosis for this group of patients presenting with severe sepsis. The diagnosis can be confounded by a lack of symptoms of pharyngitis at the time of presentation and end-organ dysfunction associated with severe sepsis, suggesting alternative sources of infection.     

Lemierre's syndrome: Diagnosis in the emergency department

A 15‐year‐old boy presented with signs of sepsis and a history of sore throat, fevers and shortness of breath. Full examination revealed an erythematous oropharynx and mild tonsillar swelling. He rapidly deteriorated requiring admission to intensive care. Blood cultures grew Fusobacterium necrophorum and an ultrasound scan performed for left neck tenderness confirmed internal jugular vein thrombosis. He was diagnosed with Lemierre's syndrome. This condition results from pharyngitis or tonsillitis with bacterial spread to the lateral pharyngeal space. Internal jugular vein thrombosis ensues with septic emboli and metastatic infections that most frequently involve the lungs. Although increasing in incidence, diagnosis is often delayed. We discuss why and describe its clinical presentation, investigations of choice and treatment strategies.     

A case of Lemierre's syndrome with double vision as the first symptom

Lemierre's syndrome is a serious disease that typically causes oropharyngeal infection with internal jugular vein thrombosis, followed by distant infection focus, such as septic pulmonary embolism. The main causative organisms are anaerobic bacteria in the oral cavity, namely Fusobacterium necrophorum. We encountered an extremely rare case of Lemierre's syndrome, where double vision was found to be the first symptom. The patient's blood culture results showed the presence of F. nucleatum, which spread from the sphenoid sinus to the skull base because of chronic sinusitis; the patient presented with longus colli abscess, clivus osteomyelitis, venous thrombosis, and hematogenous infection. Antibiotic treatment with sulbactam/ampicillin was continued for 14 weeks, and no recurrence has been observed so far. Lemierre's syndrome can be complicated with atypical symptoms such as double vision if the cranial nerves are involved. It might be important to consider this disease in the differential diagnosis in the presence of cranial nerve symptoms of unknown origin with fever or inflammatory findings.     

Comparison of Cefoxitin and Cephalothin Therapy of a Mixed Bacteroides fragilis and Fusobacterium necrophorum Infection in Mice

Cefoxitin, a beta-lactamase-resistant cephalosporin, was found to be more effective than cephalothin against an experimental mixed infection containing Bacteroides fragilis and Fusobacterium necrophorum.     

Spontaneous correction of misplaced peripherally inserted central catheters

The purpose of the present study was to examine a new protocol involving the spontaneous correction of the misplaced tip of a peripherally inserted central catheter (PICC). Patients with PICCs misplaced in the jugular or contralateral subclavian veins were recruited. All patients underwent chest X-ray (CXR) after 3 days. In addition, those whose PICC tip still was misplaced and received another CXR after 4 days. The functions of the catheters, the subjective feelings of the patients, and local symptoms of the neck and upper anterior chest wall were recorded. Among 866 patients who had PICCs, we observed 22 PICC tips misplaced in the jugular, 3 tips misplaced in the contralateral subclavian vein, and 7 tips misplaced in other locations, which was confirmed by CXR. A total of 22 PICC tips automatically returned to the superior vena cava, which included all 3 tips in the contralateral subclavian vein and 19 tips in the jugular vein. All catheters functioned normally, and the patients had no complaints. In addition, we observed no local symptoms of the neck and upper anterior chest wall. For patients experiencing a PICC misplaced in the jugular and contralateral subclavian veins, there is no need to manually replace. In addition, the function of the catheter can remain normal.     

Lemierre's syndrome: methicillin-resistant Staphylococcus aureus (MRSA) finds a new home

Lemierre's syndrome is septic thrombophlebitis of the internal jugular vein, arising as a complication of an oropharyngeal infection. This thrombophlebitis frequently results in septic emboli to organs such as the lungs. The causative agent in most previously described cases is Fusobacterium necrophorum, an anaerobic Gram-negative organism. We present the case of an 8-year-old previously healthy girl who came to the Emergency Department with a 5-day history of left-sided neck pain and was subsequently diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) Lemierre's syndrome. MRSA has not previously been described in Lemierre's syndrome in the Emergency Medicine literature. The clinical presentation, findings, and management of the syndrome are discussed. Regardless of etiology, once the diagnosis of Lemierre's syndrome is made, long-term broad-spectrum intravenous therapy will be necessary.     

Fusobacterium necrophorum septicemia without a primary focus

We have presented a case of Fusobacterium necrophorum septicemia, an uncommon infection whose early course may be typified by vague diffuse symptoms or a seemingly benign upper respiratory tract inflammation mimicking acute viral syndromes or viral pharyngitis. The septicemia is most commonly, but not always preceded by an obvious oropharyngeal focus.     

Liver abscess due to <Emphasis Type="Italic">Fusobacterium</Emphasis> species detected on ultrasonography: a case report

An oral infection harboring Fusobacterium species can gain entrance to the liver via hematogenous spread in the form of septic embolus, and can thereby cause abscesses. Such spread, described as Lemierre syndrome, is life threatening. We present such a case history of a man in his mid-40s, who presented with infection and Fusobacterium liver abscess with an acute fulminant disease course. The initial diagnosis was arrived at by ultrasound imaging and blood investigations. He was treated with antibiotics, ultrasound-guided liver abscess drainage, and extraction of the infected molar tooth. He was discharged 6 weeks after admission. To date, there have been no reports describing the ultrasound images of a Fusobacterium liver abscess in detail. Hence, we herein present the ultrasound images of a Fusobacterium liver abscess.     

A Lemierre syndrome variant caused by Staphylococcus aureus

Lemierre syndrome is a rare clinical entity, characterized by thrombosis of the internal jugular vein that develops after an oropharyngeal infection. We report the case of a 22-year-old woman hospitalized initially for cellulitis of the face. In view of the aggravation of the clinical state (septic shock and multiple organ failure), a computed tomography of the neck was performed and revealed a thrombosis of the right internal and external jugular veins. The patient was treated with antibiotics, heparin, and by a surgical excision for the vascular lesions associated with ligation of jugular veins. The patient completely recovered from her infection.     

Fusobacterium necrophorum determined as abortifacient in sheep by laser capture microdissection and fluorescence in situ hybridization

Fluorescent in situ hybridization (FISH) has been extensively used for identification of individual microbial cells within their natural environment. The present work describes the identification of Fusobacterium necrophorum in formalin-fixed tissue samples from three sets of ovine twins aborted at late pregnancy by a technique that combines laser capture microdissection (LCM) and fluorescent in situ hybridization (LCM-FISH). Cultural bacteriological examination had failed to identify an infectious agent but by histological examination, large colonies of bacteria associated with tissue inflammation were seen. In situ hybridization visualized the bacteria in the tissue samples and micro-colonies closely associated with lesions were isolated by LCM. PCR-amplification and sequencing of 16S rRNA gene from the microdissected bacteria identified the organisms as Fusobacterium necrophorum. A rRNA-targeting oligonucleotide probe specific for F. necrophorum was used in a FISH assay. In situ hybridization showed a high density of F. necrophorum in all examined tissue sections. Simultaneous probing with a general bacterial probe EUB338 and the specific probe for F. necrophorum showed that no other bacteria could be detected in the tissue sections. We therefore conclude that F. necrophorum was the likely cause of abortion in these sheep.