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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


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


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


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

Lemierre Syndrome

Lemierre Syndrome

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.