Lemierre’s syndrome

A 41-year-old, previously healthy female patient, presented with four days lasting abdominal pain. Six days prior to admission the patient felt feverish, experienced pain in the left side of the neck, swelling and difficulty with swallowing. Symptoms from the neck had subsided.  An abdominal CT was performed.

The abdominal CT showed signs of bilateral oedematous adnexa, suggesting infected ovarian cysts/ abscesses. Another finding was an enlarged, but otherwise normal, spleen. Due to continuous desaturation, a chest x-ray was performed showing atelectasis and widespread bilateral consolidation of the lower lung lobes. Additionally, an echocardiography was performed along with an ultrasound of the neck, which showed thrombosis of the internal and superficial jugular veins on the left side. Finally, the patient had a CT of the neck and chest performed that verified internal jugular vein thrombosis and additionally showed cavitary lung lesions with central necrosis, compatible with lung abscesses.

In this patient, a blood culture was positive for fusobacterium necrophorum two days after admission, which together with the radiology findings confirmed the diagnosis of Lemierre’s syndrome. Lemierre's syndrome refers to thrombophlebitis of the interal jugular vein complicated with distant metastatic sepsis preceded by an oropharyngeal infection [1]. In most cases, fusobacerium, which is normal human microflora of the oropharynx, genitourinary tract, and gastrointestinal tract, is the causative agent [2].

The imaging modality of choice for correct diagnosis of Lemierre’s syndrome is a CT of the neck with contrast enhancement because of its ability to show dilatation of the internal jugular vein with intraluminal filling defects. Alternatively, a colour Doppler ultrasound can be performed and is usually an accurate method showing an incompressible, dilated internal jugular vein with echogenic content and absence of flow [3,4]. Half of the patients suffering from Lemierre’s syndrome are children and young adults between 10-20 years (51 %) [5]5. Therefore, first-choice modality will usually be a coulor Doppler ultrasound to spare young patients from unnecessary radiation. Limitations are reduced visualisation of the thrombus, due to shadows caused by the clavicle, mandible or skull base [3,4]. A fresh thrombus will be less echogenic on ultrasound and therefore more difficult to visualise, making this imaging modality operator dependent. A third option would be MRI, which is highly sensitive to blood flow rates and provides greater soft tissue definition. Moreover, the MRI allows assessing the age of the thrombus. Disadvantages of this modality are high cost, time consumption, claustrophobia and limitations for patients with metallic implants.

With reference to our case, certain points are important to keep in mind: If a patient is admitted with an oropharyngeal infection and is diagnosed with thrombosis of the jugular vein - which may or may not subside - and subsequent complains of abdominal pain, pulmonary symptoms or pain in other organs, Lemierre’s syndrome should be considered and CT of the thorax and/or abdomen performed. Moreover, since internal jugular vein thrombosis is extremely rarely diagnosed in young patients, Lemierre’s syndrome should be considered. Likewise, if a patient is admitted with abdominal or pulmonary symptoms and the medical history reveals a recent oropharyngeal infection, it is necessary to consider scanning the abdomen and thorax to exclude Lemiere’s syndrome.

Written informed patient consent for publication has been obtained.