Sex differences in Lemierre syndrome: Individual patient-level analysis

Septic Pulmonary Embolism: A Contemporary Profile

Septic pulmonary embolism (SPE) is a rare clinical entity that is distinct from the classic and more common non-septic thrombotic pulmonary embolism. SPE should be suspected in patients with a systemic acute inflammatory reaction or sepsis who develop signs and symptoms of pulmonary involvement. The diagnosis of SPE depends on the specific radiologic finding of multiple, peripheral, nodular, possibly cavitated lesions. SPE should prompt an immediate search for the primary source of infection; typically, right-sided infective endocarditis, cardiac implantable electronic devices, and septic thrombophlebitis as a complication of bone, skin, and soft tissue infection including Lemierre's syndrome, indwelling catheters, or direct inoculation via injection drug use. Invasive treatment of the infection source may be necessary; in thrombophlebitis, the efficacy and safety of anticoagulation remain undefined. Blood cultures may be negative, particularly among patients with recent antibiotic exposure, and broad-spectrum antimicrobial therapy should be considered. The in-hospital mortality of SPE ranges up to 20% in published case series. While trends in the incidence of SPE are unknown, the opioid epidemic, the growing use of cardiac implantable electronic devices worldwide, and the reported increase in cases of septic thrombophlebitis may be leading to an escalation in SPE cases. We provide a contemporary profile of SPE and propose a clinical management algorithm in patients with suspected or confirmed SPE.

Management of Lemierre syndrome

Lemierre syndrome is a rare form of septic thrombophlebitis of the head and neck veins, most typically the internal jugular vein, which affects otherwise healthy adolescents and young adults after an oropharyngitis or other local infection and is characterized by multiple septic embolization. Despite treatment, Lemierre syndrome displays a high rate of in-hospital complications that include thrombus progression and new peripheral septic embolization, and it can be fatal or cause disabling sequelae. The mainstay of treatment is antibiotic therapy; anticoagulation is often used, but its role is controversial. Surgical treatment is often necessary in case of peripheral septic lesions. In the absence of prospective studies, what little guidance exists on its management is based on case series or on analogy with similar conditions such as other forms of septic thrombophlebitis or non-septic venous thrombosis. Over the last few years, new observational evidence has improved our knowledge of the clinical epidemiology of this condition and highlighted a number of promising management strategies. We provide an overview of the treatment patterns observed in the contemporary era, summarise the arguments proposed so far against or in favour of alternative treatments as well as possible decision rules on the use of anticoagulation, and outline the priorities of ongoing and future observational and interventional research.