Letters to the Editor

Case Report: Lemierre Syndrome Presenting with Fever and Pharyngitis



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Am Fam Physician. 2007 Apr 1;75(7):979-980.

to the editor: A 24-year-old man presented with intermittent fevers and generalized myalgias preceded by sore throat, neck pain, and rhinorrhea several weeks earlier. Physical examination revealed an erythematous oropharynx and tender, enlarged anterior cervical lymph nodes. He was diagnosed with viral pharyngitis and given instructions for symptomatic relief. The patient returned the next day complaining of persistent fever. He was now diaphoretic and appeared unwell. Vital signs included a temperature of 102.4°F (39.1°C), heart rate of 114 beats per minute, and respiratory rate of 32 breaths per minute.

Laboratory results included: an elevated white blood cell count of 16,400 cells per mm3 (16.4 × 109 per L), of which 86 percent were neutrophils; hemoglobin, 10.8 g per dL (108 g per L); platelet count, 510 × 103 per mm3 (510 × 109 per L); and liver enzymes were mildly increased. Computed tomographic scans demonstrated a 4.5-cm abscess in the right lobe of the liver and small emboli in both lung bases. Abdominal ultrasonography showed hepatic vein thrombosis. Blood cultures grew anaerobic gram-negative bacilli.

After being hospitalized and administered broad-spectrum antibiotics and anticoagulants, his symptoms resolved. Four weeks later, the infection was identified as Fusobacterium nucleatum, pointing to a diagnosis of Lemierre syndrome.

Lemierre syndrome is characterized by antecedent oropharyngeal infection, Fusobacterium septicemia, and metastatic foci of infection.1 Lemierre syndrome classically affects young, healthy males, and commonly presents with fever and recent sore throat.1,2 In the pre-antibiotic era, Lemierre syndrome was associated with a 90 percent mortality rate.3 The advent of beta-lactam antibiotics has reduced the incidence of Lemierre syndrome to 0.8 to 1.5 cases per 1 million persons per year, leading some to refer to it as the forgotten foe.4 Although potentially fatal if the diagnosis is missed, the condition is highly curable when appropriate antibiotic therapy is administered promptly.1,2

Several weeks after experiencing sore throat and neck pain, patients with Lemierre syndrome develop sepsis complicated by thromboembolic metastases.5 The lungs are the most common site of emboli, but liver involvement (as occurred in our patient) has also been reported rarely.6

Diagnosis of Lemierre syndrome is based on the identification of Fusobacterium in blood cultures. This organism is part of the oropharyngeal flora in healthy adults and normally does not cause harm. However, pharyngitis weakens the mucosal barrier and allows Fusobacterium to enter the bloodstream.5 Early detection and prompt initiation of treatment rely heavily on clinical suspicion. Imaging for multiple septic emboli may help clarify the diagnosis while awaiting culture results. Metronidazole (Flagyl) or clindamycin (Cleocin) are the first-line treatments for Lemierre syndrome because of the recent appearance of penicillin-resistant strains of Fusobacterium.5 Surgical drainage of abscesses may be indicated for patients who fail to respond to antibiotics.

Physicians should consider a diagnosis of Lemierre syndrome in young adults who present with persistent fever and signs of systemic illness after a recent oropharyngeal infection.

Author disclosure: Nothing to disclose.

REFERENCES

1. Hagelskjaer LH, Prag J, Malczynski J, Kristensen JH. Incidence and clinical epidemiology of necrobacillosis, including Lemierre's syndrome, in Denmark 1990–1995. Eur J Clin Microbiol Infect Dis. 1998;17:561–5.

2. Chirinos JA, Lichtstein DM, Garcia J, Tamariz LJ. The evolution of Lemierre's syndrome: report of 2 cases and review of the literature. Medicine. 2002;81:458–65.

3. Lemierre A. On certain septicemias due to anaerobic organisms. Lancet. 1936;1:701–3.

4. Weesner CL, Cisek JE. Lemierre syndrome: the forgotten disease. Ann Emerg Med. 1993;22:256–8.

5. Dool H, Soetekouw R, van Zanten M, Grooters E. Lemierre's syndrome: three cases and a review. Eur Arch Otorhinolaryngol. 2005;262:651–4.

6. Le Roux K, Seve P, Gomard E, Boibieux A, Beziat C, Stankovic K, et al. Lemierre syndrome variant: hepatic abscesses and hepatic vein thrombosis due toFusobacterium nucleatum septicemia [in French]. Rev Med Interne. 2006;27:482–6.

Send letters to Kenneth W. Lin, MD, MPH, Associate Deputy Editor for AFP Online, e-mail: afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680.

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