Lemierre syndrome complicating a subcutaneous neck abscess.

Abstract: Lemierre syndrome is septic thrombophlebitis of the internal jugular vein caused typically by an oropharyngeal infection. We report a case of Lemierre syndrome complicating a subcutaneous neck abscess. Lemierre syndrome should be considered in the differential diagnosis of septic emboli and sepsis, especially in a patient with tenderness along the sternomastoid muscle.

Key Words: Lemierre syndrome, septic thrombophlebitis, septic emboli

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Although he was not the first to describe the disease, Lemierre (1) wrote a comprehensive article in 1936 about a syndrome caused by an oropharyngeal infection with secondary septic thromophlebitis of the internal jugular vein and complicated by metastatic infections. He called this syndrome postanginal sepsis. This syndrome later became known as Lemierre syndrome. Lemierre stated that postanginal sepsis could be easily diagnosed clinically, before microbiologic confirmation. The syndrome starts initially as an acute oropharyngeal infection followed by septicemia with intense fevers, rigors, swelling and tenderness on the lateral aspect of the neck, parallel to the sternomastoid muscle (septic internal jugular vein thrombophlebitis) and multiple metastatic infections. (1) Lemierre syndrome has been reported as a complication of oropharyngeal infections, mastoiditis (2) and otitis media. Here, we report a case of Lemierre syndrome complicating a neck abscess secondary to "skin popping" (the subcutaneous injection of narcotics).

Case Report

A 41-year-old African-American male came to the emergency room for a swelling in the right side of his neck with purulent discharge through a sinus tract and shortness of breath of 4 days' duration. He also complained of pleuritic chest pain and cough productive of brownish sputum for 3 days. His past medical history was significant for skin popping of heroin for 20 years. He admitted to skin popping in the neck, in addition to other parts of his body, and sometimes licking the needle to "clean it" before using it.

On physical examination, he had a temperature of 98.6 [degrees]F, respiratory rate of 22 breaths/min, pulse rate of 90 beats/min and a blood pressure of 114/74 mm Hg. He had a fluctuant, tender swelling on the right side of the neck with a sinus tract opening onto the skin that was draining purulent material. Lung examination revealed decreased breath sounds in both bases and diffuse crackles. The rest of his physical examination was unremarkable. Laboratory analysis revealed a hemoglobin of 9.9 g/dL, white blood count of 23,300 cells/m[m.sup.3] with 58 segmented neutrophils, 17 band forms, 10 lymphocytes and 15 monocytes. A computed tomography (CT) scan of the neck without contrast revealed an abscess in the right side of the neck with a sinus tract leading to the skin. Chest x-ray showed mild bilateral perihilar infiltrates.

The patient was started on ceftriaxone and azithromycin for community-acquired pneumonia and had an incision and drainage of the neck abscess. Immediately after incision and drainage, the patient developed respiratory distress and was intubated and admitted to the intensive care unit. He was switched to cefepime, clindamycin and vancomycin. A CT scan of the chest revealed multiple areas of consolidation and two cavitary lesions in the left upper lobe, consistent with septic emboli (Fig. 3). A transesophageal echocardiogram was negative for vegetations. A CT scan of the neck with contrast revealed thrombosis of the right internal jugular vein (Fig. 1 and Fig. 2). A diagnosis of Lemierre syndrome following a neck abscess secondary to skin popping of heroin was made. The patient responded to IV antibiotics, cefepime and clindamycin, which were continued for a total of 4 weeks and his recovery was uneventful.

Discussion

Lemierre syndrome typically affects previously healthy teenagers and young adults and starts as an acute oropharyngeal infection. Due to anatomic proximity, the infection spreads to the internal jugular vein resulting in septic thrombophlebitis and then septicemia, which usually occurs within one week of the initial oropharyngeal infection. (3) The septicemia results in septic emboli to the lungs, joints, liver, kidneys, etc.

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The organism most commonly implicated in Lemierre syndrome is Fusobacterium necrophorum, (3) which is a strictly anaerobic, nonmotile, Gram negative bacillus. Apart from the classical lipopolysaccharide endotoxin, the bacteria also produce several exotoxins that are believed to be related to the virulence of the organism. (3) These include a heat stable leukocidin that is believed to be largely responsible for the inflammatory response associated with F. necrophorum infections and a heat labile hemolysin. (3) Aggregation of platelets caused by this organism is also believed to contribute to its virulence. (4) This aggregation of platelets may be contributing to the septic thrombus formation. (5)

High grade fever and chills are most often the initial clinical manifestations of bacteremia in Lemierre syndrome, by which time the pharyngitis may have resolved. This is usually followed by symptoms of pulmonary involvement such as pleuritic chest pain, dyspnea, and sometimes hemoptysis. Swelling and tenderness at the angle of the jaw and along the sternocleidomastoid muscle indicate internal jugular vein thrombophlebitis. Pulmonary involvement occurs in the form of septic emboli with pleural effusion, empyema and pulmonary abscesses. Other manifestations of metastatic disease include septic arthritis, liver abscesses and renal involvement. Hyperbilirubinemia and increased alkaline phosphatase levels may occur related to the bacteremia even in the absence of a liver abscess. (3)

An enhanced computed tomography of the neck is the investigation of choice to demonstrate the internal jugular vein thrombosis. (3) Blood cultures may grow Fusobacterium necrophorum.

Prolonged treatment with antibiotics active against anaerobic organisms, such as clindamycin, metronidazole and cefoxitin is necessary. (6) Drainage of purulent collections may be needed. Ligation and resection of the internal jugular vein should be reserved for patients with uncontrolled sepsis and severe respiratory failure due to repeated septic pulmonary emboli. (3)

It is important for the physician to be aware of this clinical entity, as early recognition and prompt and prolonged treatment with antibiotics active against anaerobes is vital in these patients.

References

1. Lemierre A. On certain septicemias due to anaerobic organisms. Lancet 1936;2:701-703.

2. Shetty AK, Begue RE, Coffman K, et al. Lemierre's syndrome following mastoiditis. Infect Med 1998;15:323-332.

3. Sinave CP, Hardy GJ, Fardy PW. The Lemierre syndrome: suppurative thrombophlebitis of the internal jugular vein secondary to oropharyngeal infection. Medicine (Baltimore) 1989; 68: 85-94.

4. Forrester LJ, Campbell BJ, Berg JN, et al. Aggregation of platelets by Fusobacterium necrophorum. J Clin Microbiol 1985;22: 245-249.

5. Stahlman GC, DeBoer DK, Green NE. Fusobacterium osteomyelitis and pyarthrosis: a classic case of Lemierre's syndrome. J Pediatr Orthop 1996; 16:529-532.

6. Bach MC, Roediger JH, Rinder HM. Septic anaerobic jugular phlebitis with pulmonary embolism: problems in management. Rev Infect Dis 1988;10:424-427.

Kalpana Raghunathan, MD, and Nagapradeep Nagajothi, MD

From the Department of Internal Medicine, Rosalind Franklin University of Medicine and Sciences, North Chicago, IL.

Reprint requests to Kalpana Raghunathan, MD, Department of Internal Medicine, Mount Sinai Hospital, California Avenue at 15th Street, Chicago, IL 60608. Email: [e-mail]

Accepted November 28, 2005.

RELATED ARTICLE: Key Points

* Lemierre syndrome is septic thrombophlebitis of the internal jugular vein caused typically by an oropharyngeal infection.

* It commonly results in septicemia and septic emboli to the lungs and other organs.

* The inciting infection may have resolved by the time the patient presents with septicemia.

* Swelling and tenderness at the angle of the jaw and along the sternomastoid muscle should raise the suspicion of thrombophlebitis of the internal jugular vein.

* Enhanced CT scan of the neck is the investigation of choice.

Give every man thy ear, but few thy voice.
--William Shakespeare