Lemierre Syndrome (Postanginal sepsis or Necobacilloosis)
Submitted by Thomas J Reilly, MD

General Considerations

• Seen in young adults who may be otherwise healthy
• Refers to rare thrombophlebitis of the internal jugular vein with distant metastatic sepsis seen in the setting of initial oropharyngeal infection (pharyngitis / tonsillitis with or without peri-tonsillar abscess
• More common in pre-antibiotic era
  • 90% mortality before antibiotics
• Most common pathogen is Fusobacterium necrophorum
  • Component of normal oropharyngeal flora
  • Unusual ability to invade locally without underlying disease
• Also other gram negative organisms
• In 1936, Lemierre described the condition
  • Had been reported in 1918 by Schottmuller

Clinical Findings

• Infection of parapharyngeal space (via direct, lymphatic or tonsillar venous routes) spreads to carotid space, where it can result in ipsilateral jugular venous thrombosis)
• Venous contamination then acts as a nidus for septicemia and septic embolization
• Pulmonary septic emboli seen in as high as 90% in some series
• Patients may initially present with acute pharyngitis
• Followed by fever, rigors and malaise as sepsis develops
• Trismus and neck pain/swelling may present before sepsis
• Tenderness, swelling, and pain over the angle of the jaw may also be present

Imaging Findings

• Contrast-enhanced CT is the imaging study of choice in finding the inciting abscess
  • Distended veins
• Enhancing walls
• Intraluminal filling defects
• Adjacent soft tissue infiltration
• Because of its ease of accessibility, the internal jugular can be studied by ultrasound
• Localized echogenic clot

Differential Diagnosis

• Peritonsillar abscess
• Pharyngitis

Treatment

• High-dose parenteral antibiotics
• Anticoagulation
• Ligation or resection of the internal jugular vein on occasion

Complications

• Pulmonary septic emboli
• Empyema
• Lung abscess
• Septic arthritis, osteomyelitis or hepatic abscesses through a patent foramen ovale

Prognosis

• In antibiotic era,  the disease has a reported mortality rate of 6.4% 

Lemierre Syndrome. Top: Gray-scale and color Doppler images of the left internal jugular vein show non-occlusive thrombus (white arrows) in the internal jugular vein. Bottom: Axial, sagittal and coronal images from a contrast enhanced CT scan of the neck show a rim-enhancing hypodense collection, representing an abscess, in the left peritonsillar region (black arrows). (Images courtesy St. Christopher’s Hospital for Children)
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Septic Thrombophlebitis. eMedicine. N Connors.