Key Points
- Think of LS in post‑pharyngitis sepsis with neck pain and lung nodules.
- Order venous‑phase imaging of the neck to demonstrate IJV thrombus.
- Start anaerobe‑active antibiotics promptly and treat for weeks, not days.
- Anticoagulation use is case‑by‑case for extensive or progressive thrombosis.
Algorithm
- Primary survey and stabilization; focused history and exam.
- Order high‑yield tests first; escalate imaging as indicated.
- Initiate disease‑specific therapy and supportive care.
- Reassess clinical response; arrange consultation and disposition.
Clinical Synopsis & Reasoning
Young, previously healthy patient with recent oropharyngeal infection develops fever, neck pain, and septic emboli. Suspect Lemierre syndrome—septic thrombophlebitis of the internal jugular vein—most often due to Fusobacterium necrophorum. Clinical reasoning integrates antecedent pharyngitis/tonsillitis, lateral neck tenderness, and pulmonary nodules/abscesses on CT. Obtain blood cultures before antibiotics. Contrast-enhanced CT neck with venous phase or MRV demonstrates IJV thrombus and perivenous inflammation. Consider alternative pathogens (Streptococcus spp., Staphylococcus aureus) and abdominal variants (pylephlebitis).
Treatment Strategy & Disposition
Start broad-spectrum IV antibiotics with excellent anaerobic coverage (e.g., piperacillin–tazobactam or ceftriaxone plus metronidazole) then tailor to Fusobacterium when confirmed; duration typically 3–6 weeks. Consult ENT/ID. Anticoagulation is individualized for extensive IJV thrombosis or clot propagation; evidence is limited. Drain abscesses when accessible; admit to ICU if respiratory failure or septic shock.
Epidemiology / Risk Factors
- Epidemiology varies by setting; see citations for details.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| Blood cultures ×2–3 | Identify Fusobacterium or streptococci | Anaerobic Gram‑negative rods | Draw prior to antibiotics |
| CT neck with contrast / MRV | Confirm IJV thrombosis, map extent | IJV thrombus, perivenous fat stranding | Venous phase essential |
| CT chest | Look for septic emboli/abscess | Multiple nodules ± cavitation | If resp symptoms/hypoxemia present |
| Inflammatory markers | Support severity, trend response | Leukocytosis, ↑CRP | Non‑specific |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Piperacillin–tazobactam | β‑lactam/β‑lactamase inhibitor | Minutes | Empiric broad coverage incl. anaerobes | Renal dosing; sodium load |
| Ceftriaxone + Metronidazole | 3rd‑gen cephalosporin + nitroimidazole | Hours | Alternative empiric combo | Biliary sludging (ceftriaxone); disulfiram‑like (metronidazole) |
| Ampicillin–sulbactam | β‑lactam/β‑lactamase inhibitor | Minutes | Step‑down IV if stable | Renal dosing |
| Amoxicillin–clavulanate (PO) | β‑lactam/β‑lactamase inhibitor | Hours | Oral completion therapy | GI upset, hepatotoxicity |
Prognosis / Complications
- Prognosis depends on timeliness of diagnosis, comorbid disease, and response to therapy.
Patient Education / Counseling
- Explain expected course, warning signs requiring urgent care, and follow‑up testing.
- Review medication use, interactions, and monitoring parameters.