EM in 5: Lemierre’s Syndrome

Author: Anna Pickens, MD (@AnnaEMin5, Creator of EMin5) // Edited by:Alex Koyfman, MD (@EMHighAK), Brit Long, MD (@long_brit), and Manpreet Singh, MD (@MprizzleER)

Welcome to this week’s edition of EMin5 by Dr. Anna Pickens. Today we are focusing on Lemierre’s Syndrome:

Let’s start out with a case:

We have a 19 yo female, otherwise healthy who goes to her PMD with sore throat, fever, and chills for the last few days. The rapid strep is negative, so she is discharged with likely viral pharyngitis.

But then a few days later she presents to the ER looking toxic – she has fever of 103, is dehydrated, has a cough, is feeling short of breath, satting 92%.  And she still has that throat pain, only now it is much worse on the right side.

A chest xray shows bilateral infiltrates. Hmm…

Now we should be getting worried.  Why would this normally healthy patient have bilateral infiltrate and signs of sepsis?  Septic emboli!  And with this history of unilateral sore throat, we should have a high suspicion for Lemierre’s syndrome.

CT of the neck confirms a right IJ clot.

Let’s talk Lemierre’s!

Lemierre’s is an infectious thrombophlebitis of the internal jugular vein.

It starts out as a common oropharyngeal infection, such as pharyngitis, tonsillitis, peritonsillar abscess, or dental infection.

But then if it goes untreated, it can spread to the parapharyngeal space (ie become a deep space neck infection), and get into the carotid sheath.

Once it penetrates the carotid sheath, it is only a matter of time before the patient becomes bacteremic and a clot forms in the IJ.   From there, septic emboli can fly throughout the body, landing in the liver, lungs, endocardium, and joints.

Historically the mortality of Lemierre’s was 90%, but even today it can be up to 15%, which is pretty significant.  Part of that risk is that this is a tough diagnosis to make and usually requires a few visits to the healthcare system before a diagnosis is made.  So we have to have a high index of suspicion!

What should we be looking for?

Patients presenting with neck or throat pain that is unilateral, as well as signs of infection such as swelling and fevers.

THEN… add to this some evidence of systemic spread.

And here’s the big clue:  97% have septic emboli to the lungs!  So look for pneumonia, especially if there are multiple foci.

To make the diagnosis, we need a CT (or ultrasound) of the neck, looking for evidence of an IJ clot.

You also might find the following abnormalities:

The bacteria most associated with Lemierre’s is Fusobacterium necrophorum.  Start antibiotics:

Anticoagulation for the IJ thrombus is controversial. Consider discussing with vascular, as it may depend on how extensive the clot is and what management they recommend.