Persistent fever, left-sided neck pain, night sweats—Dx?

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Case Reports

Persistent fever, left-sided neck pain, night sweats—Dx?

J Fam Pract. 2014 April;63(4):193-196

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References

1. Golpe R, Marin B, Alonso M. Lemierre’s syndrome (necrobacillosis). Postgrad Med J. 1999;75:141-144.

2. Wright WF, Shiner CN, Ribes JA. Lemierre syndrome. South Med J. 2012;105:283-288.

3. Riordan T, Wilson M. Lemierre’s syndrome: more than a historical curiosa. Postgrad Med J. 2004;80:328-334.

4. Ridgway JM, Parikh DA, Wright R, et al. Lemierre syndrome: a pediatric case series and review of literature. Am J Otolaryngol. 2010;31:38-45.

5. McCaig LF, Besser RE, Hughes JM. Antimicrobial drug prescription in ambulatory care settings, United States, 1992–2000. Emerg Infect Dis. 2003;9:432-437.

6. Hagelskjaer Kristensen L, Prag J. Human necrobacillosis, with emphasis on Lemierre’s syndrome. Clin Infect Dis. 2000;31:524-532.

7. Kupalli K, Livorsi D, Talati N, et al. Lemierre’s syndrome due to fusobacterium necrophorum. Lancet Infect Dis. 2012;12:808-815.

8. Armstrong AW, Spooner K, Sanders JW. Lemierre’s syndrome. Curr Infect Dis Rep. 2000;2:168-173.

9. Screaton NJ, Ravenel JG, Lehner PJ, et al. Lemierre syndrome: forgotten but not extinct--report of four cases. Radiology. 1999;213:369-374.

10. Chirinos JA, Lichtstein DM, Garcia J, et al. The evolution of Lemierre syndrome: report of 2 cases and review of the literature. Medicine (Baltimore). 2002;81:458-465.

11. Karkos PD, Asrani S, Karkos CD, et al. Lemierre syndrome: a systematic review. Laryngoscope. 2009;119:1552-1559.

12. Phan T, So TY. Use of anticoagulation therapy for jugular vein thrombus in pediatric patients with Lemierre’s syndrome. Int J Clin Pharm. 2012;34:818-821.

13. O’Brien WT, Cohen RA. Lemierre’ syndrome. Applied Radiology. 2011;40:37-38.

14. Vandenberg SJ, Hartig GK. Lemierre’s syndrome. Otolaryngol Head Neck Surg. 1998;119:516-518.

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CT scan of the neck and chest with contrast is the optimal diagnostic modality because it allows physicians to visualize the IJV⁸ and detect pulmonary emboli.⁹ Doppler ultrasound also can be used to diagnose IJV thrombosis. Ultrasound findings would reveal an echogenic focus within a dilated IJV or a complex mass of cystic and solid components.¹⁰

Many case reports have demonstrated that complete recovery is possible without anticoagulation.Prompt antibiotic treatment is essential

Patients with Lemierre’s syndrome require prompt and appropriate antimicrobial therapy. Researchers have reported mortality rates of 25% among patients who received delayed antibiotic therapy, compared with rates of up to 18% with prompt therapy.³ Metronidazole is the most commonly prescribed antibiotic.⁸ When combined with ceftriaxone, it provides coverage for both F necrophorum and streptococci, a common copathogen. Monotherapy with a carbapenem antibiotic, clindamycin, ampicillin/sulbactam, or antipseudomonal penicillin also are appropriate options.⁵ Antimicrobial treatment for 3 to 6 weeks is recommended because relapses have been noted in patients treated for less than 2 weeks.¹¹

Anticoagulation is controversial.² Proponents of anticoagulation to treat Lemierre’s syndrome believe it may prevent formation of septic emboli and could expedite recovery.^4,12 Others believe that clots associated with Lemierre’s syndrome dissolve on their own and that anticoagulation may increase the likelihood of septic emboli.¹³ Many case reports, including this one, have demonstrated that complete recovery is possible without anticoagulation.^10,13-15Anticoagulation therapy can be considered for patients with Lemierre’s syndrome in the absence of any contraindications such as gastrointestinal or intracranial bleeding.

THE TAKEAWAY

Suspect Lemierre’s syndrome when a patient complains of neck pain, high fever, rigors, dry cough, and pleuritic chest pain and mentions a sore throat that he or she had in the pretceding 7 days. Diagnosis can be confirmed by radiological findings and blood cultures positive for F. necrophorum. Patients with Lemierre’s syndrome should be promptly treated with antibiotics; evidence for anticoagulation is inconclusive.

Persistent fever, left-sided neck pain, night sweats—Dx?

References

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