Letters to the Editor
Management of Diabetes Should Be a Team Approach
to the editor: The article, "Tight Control of Type 1 Diabetes: Recommendations for Patients,"1 provided a nice basic discussion of type 1 diabetes; however, it only made one statement, in passing, about certified diabetes educators. This was a striking omission.
Frankly, it is absurd to expect this complex and burdensome disease to be managed by only the physician and the patient. As a board-certified endocrinologist, physician nutrition specialist, and certified diabetes educator providing care for patients with types 1 and 2 diabetes over the past 22 years, I understand the fundamental need for an ongoing, interdisciplinary approach to this disease. Education regarding self-management of diabetes provided by certified diabetes educators is strongly endorsed by all expert organizations (e.g., American Diabetes Association,2 American College of Endocrinology, the Endocrine Society). Physicians alone, regardless of their specialty, cannot be expected to provide adequate instructions in such areas as carbohydrate counting, proper insulin injection technique, or insulin dose adjustment.
I urge physicians who care for patients with type 1 or type 2 diabetes to routinely utilize the expertise of certified diabetes educators. To find educators in a specific community, physicians and patients can visit the online resource for the American Association of Diabetes Educators at http://www.diabeteseducator.org.
Author disclosure: Dr. Weiss is on the speakers' bureau for Amylin Pharmaceuticals.
REFERENCES
1. Havas S, Donner T. Tight control of type 1 diabetes: recommendations for patients. Am Fam Physician 2006;74:971-8.
2. American Diabetes Association. Third-party reimbursement for diabetes care, self-management education, and supplies. Diabetes Care 2006;29(suppl 1):S68-9.
Case Report: Lemierre Syndrome Presenting with Fever and Pharyngitis
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 to Fusobacterium nucleatum septicemia [in French]. Rev Med Interne 2006;27:482-6.
The article "Retinoblastoma" (March 15, 2006, page 1039) contained an error in the legend for Figure 2 on page 1041. The figure legend incorrectly identified the figure as an ultrasound B scan of the left eye rather than a computed tomography scan. The figure legend should have read as follows: "Computed tomography scan of the left eye, with a large mass filling the vitreous cavity. Areas of calcification appear as hyper-reflective spots (arrow)." The online version of this article has been corrected.
Send letters to Kenny Lin, M.D., Assistant Editor, American Family Physician, e-mail: afplet@aafp.org. Letters submitted via regular mail should be sent to: 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-6272.
Please include your complete address, telephone number, fax number, and e-mail address. Letters should be fewer than 500 words and limited to one table or figure and six references (including citation of original article). Please submit a word count.
Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the American Academy of Family Physicians permission to publish the letter in any of its publications in any form. Letters will be edited to meet style and space requirements.
| Copyright © 2007 by the American
Academy of Family Physicians. |
