Lemierre Syndrome

Aka: Lemierre Syndrome, Fusobacterium Pharyngitis, Fusobacterial Necrotizing Tonsillitis, Fusobacterium Necrophorum, Septic Thrombophlebitis of Internal Jugular Vein, Internal Jugular Vein Suppurative Thrombophlebitis, Postanginal Sepsis

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II. Epidemiology

  1. Adolescents and young adults make up majority of cases

III. Pathophysiology

  1. First described by Andre Lemierre in 1936
  2. Infection by Fusobacterium necrophorium (Lemierre Syndrome)
    1. Responsible for 10% of acute Pharyngitis cases in young adults and adolescents
  3. Occurs with contiguous infection from Pharyngitis (typically) or Dental Infection to lateral pharyngeal space
  4. Results in Septic Thrombophlebitis of Internal Jugular Vein
    1. Fusobacterium promotes Platelet aggregation without lysis

IV. Causes: Septic Thrombophlebitis of Internal Jugular Vein

  1. Infection by Fusobacterium necrophorium (Lemierre Syndrome)
  2. Jugular Central Line Infection (Staphylococcus Aureus)
  3. Septic emboli (e.g. Lung Abscess, Osteomyelitis)

V. Signs

  1. Fever
  2. Tonsillar exudates
  3. Anterior Cervical Lymphadenopathy
  4. Cough absent

VI. Differential Diagnosis

  1. Peritonsillar Abscess
  2. Retropharyngeal Abscess
  3. Dental Infection (e.g abscessed tooth, Retromolar abscess)
  4. Epiglottitis
  5. Mononucleosis

VII. Management: Consider empiric treatment

  1. Emergent ENT Consultation for surgical drainage
  2. Antibiotics: Fusobacterium necrophorium (Lemierre Syndrome)
    1. Metronidazole 500 mg IV and Ceftriaxone 2 g IV every 24 hours OR
    2. Piperacillin-Tazobactam (Zosyn) 4.5 g IV every 6 hours OR
    3. Carbapenem (e.g. Imipenem, Meropenem or Ertapenem) OR
    4. Clindamycin 900 mg IV every 8 hours (risk of resistance)
    5. Other Antibiotics with coverage: Amoxicillin-Clavulanate (resistance risk) and Cefoxitin
    6. Avoid Macrolides (Fusobacterium resistance)
  3. Antibiotics: Staphylococcus Aureus (infected Internal Jugular Central Line source)
    1. Vancomycin
  4. Duration Antibiotics: 3-6 weeks

VIII. Complications

  1. High morbidity and mortality
  2. Metastatic infection
  3. Septic pulmonary emboli
  4. Carotid Artery erosion (with life-threatening bleeding)

IX. References

  1. (2018) Sanford Guide, accessed on IOS 1/13/2020
  2. Edson (2011) Internal Medicine, Mayo Conference, Kauai
  3. Guess and Pittman (2022) Crit Dec Emerg Med 36(7): 12-4
  4. Centor (2010) Ann Intern Med 152(7): 477-8 [PubMed]
  5. Kuppalli (2012) Lancet Infect Dis 12(10):808-15 [PubMed]

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