Lemiere's syndrome

Introduction

a rare syndrome caused by the anaerobe F. necrophorum secondary to oropharyngeal infections mainly in 18-35 yr olds
infection extends from the pharynx into the parapharyngeal spaces of the neck and then causes septic thrombophlebitis of the internal jugular vein
infection may also extend into cervical veins and the mediastinal structures
once infection has invaded the cervical veins, septic emboli occur - 85% to the lungs, but other organs, bones and meninges may become septic from the emboli

preceding oropharyngeal infection
unilateral neck tenderness and swelling
25-45% have a “cord sign” - palpable swelling and tenderness at the mandibular angle which suggests thrombophlebitis of the internal jugular vein
7% develop septic shock

high inflammatory markers (WCC, CRP) with substantively raised D-Dimer help support the clinical diagnosis
US can be useful but has lower sensitivity than CT with contrast or MRV due to low echogenicity of fresh clots combined with anatomic constraints of the lower neck
CT scan with venous phase contrast
MRV of the neck has higher sensitivity than CT with contrast
Blood cultures grow Fusobacterium in ~70% of cases but take 2-7 days

IV antibiotics
- usually start with a beta-lactamase-resistant beta-lactam antibiotic then adjust as per culture results
generally requires a 6 week course of antibiotics to ensure adequate penetration of fibrin clots
surgical drainage of any abscesses
advanced infection may require ICU
- mortality is 5-18% in these cases despite antibiotics and surgical drainage
- septic emboli and end-organ effects can result in long-term morbidity
possible indications for anticoagulation:
- thrombus extends into the cerebral sinuses
- large or bilateral clot burden
- patient fails to improve in the first 72 hours with appropriate antibiotic and/or surgical therapy.