A young woman with a sore throat, septicaemia, and respiratory failure

Emphysematous Osteomyelitis of the Spine: A Case Report and Literature Review

Emphysematous osteomyelitis is a rare but potentially fatal infection. It is caused by gas-forming organisms and is characterized by the presence of intraosseous gas. A 75-year-old woman with untreated diabetes mellitus presented with difficulty in moving and anorexia. Laboratory studies revealed inflammation, a urinary infection, and diabetic ketoacidosis. Klebsiella pneumoniae was detected in both urine and blood cultures. Computed tomography and magnetic resonance imaging revealed emphysematous lesions in the paravertebral soft tissue, spinal canal, and iliopsoas muscle, with intraosseous gas at L1 and L2. These findings led to a diagnosis of emphysematous osteomyelitis. We herein review 35 reported cases of emphysematous osteomyelitis including our case.

Emphysematous Osteomyelitis due to Escherichia coli

Emphysematous osteomyelitis, especially that involving the extra-axial skeleton, is an extremely rare presentation but associated with significant morbidity and mortality. Here, we report a case in which a 58-year-old female patient with diabetes mellitus presented with emphysematous osteomyelitis that involved the sternum, clavicle, and pelvic bone and was caused by Escherichia coli via hematogenous spread of urinary tract infection. We successfully treated her with urgent and aggressive surgical drainage with prolonged antibiotics therapy. Early diagnosis and immediate surgical intervention are required for better outcomes in cases of emphysematous osteomyelitis.

Lemierre's syndrome from odontogenic infection: Review of the literature and case description

Lemierre's syndrome (LS) is a rare potentially fatal sequel of head and neck infection, classically described as thrombophlebitis of the internal jugular vein (IJV) with cervical space infection extending into the thorax. Our objective was to answer the clinical question: "Does Lemierre syndrome (LS) from odontogenic infection differ from nonodontogenic LS in regard to clinical sequence, treatment, and survival." We reviewed the literature on the management of LS over the last two decades, with a focus on LS from odontogenic infection. Such a case is presented in order to portray the clinical sequence. Only 10 cases met the inclusion criteria (including the case presented). The recorded data were analyzed in comparison to large case series reviewing LS. Our data reflect the moderate differences in regard to IJV thrombosis and bacteriogram. There is an overall rise in published LS cases in the last 20 years. Odontogenic infection leading to LS is scarce, yet with survival rates similar to nonodontogenic LS. Repeated surgical interventions and aggressive wide spectrum antibiotic therapy remain the treatment of choice.

Lemierre's syndrome due to intratumoral abscess of the uvula

Lemierre’s syndrome (LS), described in detail in 1936, used to be a life-threatening entity until the advent of antibiotics. Tonsillitis or pharyngitis are the main primary infections and oropharyngeal anaerobic flora is the predominant etiology. However, other primary site infections, as well as other microbiological agents have been reported since the first description. Inflammatory symptoms in the neck and marked findings on physical examination predominate the majority of cases. Nonetheless, the authors report the case of a 54-year-old man with a history of dysphagia followed by cough, purulent expectoration, and fever. The bad condition of his dentition was noteworthy. During the diagnostic work-up, an ulcerated lesion in the uvula and a middle lobe pneumonia were disclosed. Streptococcus viridans was isolated from blood culture. On the fifth day of hospitalization, the patient died after a copious episode of hemoptysis. The autopsy findings depicted an abscess within a squamous cell carcinoma of the uvula, pharyngitis with carotid sheath spreading accompanied by pylephlebitis and thrombosis of the internal jugular vein up to the innominate vein, surrounded by an abscess in the mediastinum. Alveolar hemorrhage and pneumonia were also present. We conclude that the ulcerated carcinoma of the uvula housed an abscess, facilitated by the poor oral hygiene, which triggered LS and the descending mediastinitis. Pulmonary involvement was due to the septic embolism from the internal jugular vein. We would like to highlight the uvula abscess as the primary site of infection in this case of LS with S. viridans as the causative agent.

Lemierre's syndrome due to Fusobacterium necrophorum

We present a case of a patient with Lemierre's syndrome caused by Fusobacterium necrophorum who developed a right frontal lobe brain abscess. We summarise the epidemiology, microbiology, pathogenesis, clinical presentation, diagnosis, complications, therapy, and outcomes of Lemierre's syndrome. F necrophorum is most commonly associated with Lemierre's syndrome: a septic thrombophlebitis of the internal jugular vein. Patients usually present with an exudative tonsillitis, sore throat, dysphagia, and unilateral neck pain. Diagnosis of septic thrombophlebitis is best confirmed by obtaining a CT scan of the neck with contrast. Complications of the disease include bacteraemia with septic abscesses to the lungs, joints, liver, peritoneum, kidneys, and brain. Treatment should include a prolonged course of intravenous beta-lactam antibiotic plus metronidazole.

Emphysematous osteomyelitis: a case report and review of the literature

We report the case of a 15-year-old girl with pelvic and sacral emphysematous osteomyelitis caused by Fusobacterium necrophorum. This infection was cured following four surgical procedures and 4 weeks of intravenous then 4 weeks of oral antibiotics. We review our case alongside the 24 previously reported cases of emphysematous osteomyelitis in the literature. The 25 cases include 15 monomicrobial and 10 polymicrobial infections. The causative organism(s) in all but three cases included an anaerobe or a member of the Enterobacteriaceae family. A significant underlying comorbidity was reported in 18 cases. At least 15 cases required one or more surgical procedures. There was a significant associated mortality with eight (32%) patients dying in hospital at 7 to 56 days after the diagnosis of emphysematous osteomyelitis.

Eponym: the Lemierre syndrome

Fig. 1 Dr. Andre Lemierre Lemierre syndrome, also known as postanginal sepsis, is a severe complication of an acute oropharyngeal infection that results in septic thrombophlebitis of the ipsilateral internal jugular vein with subsequent septicemia, often complicated by metastatic infections. The usual agent in Lemierre syndrome is Fusobacterium necrophorum, a commensal bacillus of the oral cavity. After the advent of antibiotic therapy, especially in the 1960s and 1970s, when penicillin was frequently used to treat pharyngeal infections, Lemierre syndrome was often referred to as the "forgotten disease". Today with increasing antibiotic-resistant organisms and decreasing awareness of the syndrome, subsequent reemergence of this syndrome is becoming more common in clinical settings. The syndrome starts initially as an acute oropharyngeal infection followed by septicemia with intense fevers, rigors, swelling, and tenderness on the lateral aspect of the neck, parallel to the sternomastoid muscle (septic internal jugular vein thrombophlebitis), and multiple metastatic infections.

Lemierre's syndrome with paradoxical emboli

Lemierre's syndrome is a rare anaerobic oropharyngeal infection complicated by internal jugular thrombosis, the predominant etiology is Fusobacterium necrophorum. Septic emboli to lungs and distant organs have been described, however, to date there have been no published cases associated with embolization across a patent foramen ovale. We describe a case of Lemierre's syndrome with septic arterial emboli resulting in multiple cerebral abscesses and cutaneous manifestations. The outcome was favorable with appropriate antimicrobial therapy.

Lemierre's syndrome following infectious mononucleosis

We report the case of an 18-year-old woman who was admitted to the medical intensive care unit in Innsbruck with severe septic shock and respiratory insufficiency following a prolonged infection of the upper airways (pharyngitis, sinusitis). Abscessing pneumonia and bilateral pleural empyema were diagnosed as focus. Cultures of pleural fluids were positive for Fusobacterium necrophorum. In addition to multiple organ dysfunction syndrome (acute lung injury, acute renal failure, disseminated intravascular coagulation), she developed tenderness in the right neck followed by septic arthritis of the right sternoclavicular joint a few days later. Further history revealed a previous period of infectious mononucleosis (EBV infection). The previously healthy patient eventually made a complete recovery after prolonged treatment in the ICU including antibiotic therapy and multiple surgical interventions and drainage. Lemierre's syndrome is characterized by severe infection, with pharyngitis, sepsis and thrombosis of the internal jugular vein, and is most frequently associated with upper airway infection with Fusobacterium necrophorum, often preceded by infection with Epstein-Barr virus which enables bacteria growing in the oral cavity to invade.

Human infection with Fusobacterium necrophorum (Necrobacillosis), with a focus on Lemierre's syndrome

Human infection with Fusobacterium necrophorum usually involves F. necrophorum subsp. funduliforme rather than F. necrophorum subsp. necrophorum, which is a common pathogen in animals. Lemierre's syndrome, or postanginal sepsis, is the most common life-threatening manifestation. Tonsillitis is followed by septic thrombophlebitis of the internal jugular vein and then a septicemia with septic emboli in lungs and other sites. Recent evidence suggests that F. necrophorum can be limited to the throat and cause persistent or recurrent tonsillitis. F. necrophorum is unique among non-spore-forming anaerobes, first for its virulence and association with Lemierre's syndrome as a monomicrobial infection and second because it seems probable that it is an exogenously acquired infection. The source of infection is unclear; suggestions include acquisition from animals or human-to-human transmission. Approximately 10% of published cases are associated with infectious mononucleosis, which may facilitate invasion. Recent work suggests that underlying thrombophilia may predispose to internal jugular vein thrombophlebitis. Lemierre's syndrome was relatively common in the preantibiotic era but seemed to virtually disappear with widespread use of antibiotics for upper respiratory tract infection. In the last 15 years there has been a rise in incidence, possibly related to restriction in antibiotic use for sore throat.

Lemierre Syndrome: Two Cases and a Review

OBJECTIVES

Lemierre syndrome is usually caused by an acute oropharyngeal infection in previously healthy young adults, resulting in thrombophlebitis of the internal jugular vein, leading to metastatic septic embolization and bacteraemia. The usual organism is Fusobacterium necrophorum. Lemierre syndrome, not so long ago labeled as the "forgotten disease," is on the rise. Today with increasing antibiotic-resistant organisms, and decreasing awareness of the syndrome, subsequent re-emergence of this "forgotten disease" is becoming more common in clinical settings. Lemierre syndrome has significant morbidity. Cranial nerve complications associated with the condition have been increasingly diagnosed in the last few years. Looking back at literature on Lemierre syndrome, there have been review articles in medical and microbiology journals but rarely in otolaryngology journals. By presenting our cases we demonstrate the diverse presentations and severity of the illness.

METHODS

A review of the literature and a case report on two cases seen in our institution in the last year are presented. Each of these had varied presentations and neurologic complications-one developed 9th to 12th cranial nerve palsies and Horner syndrome, which have not been described in previous literature, and the other developed polyneuropathy and a frontal lobe infarct among other multisystem complications.

CONCLUSIONS

Diagnosis of Lemierre syndrome is not always straightforward as clinical features are variable and blood cultures are often negative. Awareness of the syndrome and a high degree of suspicion are needed.

Lemierre syndrome: a case of postanginal sepsis

Lemierre syndrome is a rare disease that's characterized by internal jugular vein thrombosis and septic emboli. These symptoms typically develop after acute oropharyngeal infection by Fusobacterium necrophorum. Although this syndrome is less frequently seen in modern times due to the availability of antibiotics, physicians must be aware of the syndrome in order to initiate prompt antibiotics therapy, including coverage of the anerobic organisms. We discuss here the case of an 18-year-old female with Lemierre syndrome and we review the relevant literature on this syndrome.

Cerebral infarctions and brain abscess due to Lemierre syndrome

Lemierre syndrome is characterized by anaerobic bacterial infection in the head and neck, causing thrombophlebitis of the jugular vein and septic metastasis to various distant organs, most often the lungs. Here we describe previously unreported clinical features of cerebral infarctions and brain abscess due to metastatic septic embolism of this uncommon but lethal syndrome, and the successful course of treatment with ampicillin, cefotaxime and metronidazole.

Lemierre's syndrome: more than a historical curiosa

Lemierre's syndrome is a severe illness caused by the anaerobic bacterium, Fusobacterium necrophorum which typically occurs in healthy teenagers and young adults. The infection originates in the throat and spreads via a septic thrombophlebitis of the tonsillar vein and internal jugular vein. The ensuing bacteraemia is complicated by septic emboli to a range of sites such as lung, joints, and bones. Although rare, there is evidence of a resurgence in the condition in recent years, possibly associated with reduced use of antibiotic therapy for sore throats. The typical clinical picture is characteristic but many clinicians are unaware of the condition and diagnosis is often delayed with potentially fatal consequences.

The evolution of Lemierre syndrome: report of 2 cases and review of the literature

Lemierre syndrome (postanginal septicemia) is caused by an acute oropharyngeal infection with secondary septic thrombophlebitis of the internal jugular vein and frequent metastatic infections. A high degree of clinical suspicion is necessary for diagnosis. Fusobacterium necrophorum is the usual etiologic agent. The disease progresses in several steps. The first stage is the primary infection, which is usually a pharyngitis (87.1% of cases). This is followed by local invasion of the lateral pharyngeal space and IJV septic thrombophlebitis (documented in 71.5% of cases), and finally, the occurrence of metastatic complications (present in 90% of cases at the time of diagnosis). A sore throat is the most common symptom during the primary infection (82.5% of cases). During invasion of the lateral pharyngeal space and IJV septic thrombophlebitis, a swollen and/or tender neck is the most common finding (52.2% of patients) and should be considered a red flag in patients with current or recent pharyngitis. The most common site of metastatic infection is the lungs (79.8% of cases). In contrast to the preantibiotic era, cavitating pneumonia and septic arthritis are now uncommon. Most patients (82.5%) had fever at some stage during the course of the disease. Gastrointestinal complaints such as abdominal pain, nausea, and vomiting were common (49.5% of cases). An elevated white blood cell count occurred in 75.2% of cases. Hyperbilirubinemia with slight elevation of liver enzyme levels occurred in one-third of patients, but frank jaundice was uncommon, in contrast to its high frequency reported in the preantibiotic era. We conclude that, most likely as a consequence of widespread antibiotic use for pharyngeal infections, the typical course of the disease has changed since Lemierre's original description. The typical triad in our series was: pharyngitis, a tender/swollen neck, and noncavitating pulmonary infiltrates. The previous classical description of severe sepsis with cavitating pneumonia and septic arthritis was not commonly seen in our review. Mortality was low in our series (6.4%), but significant morbidity occurred, which was likely preventable by early diagnosis and treatment. The pathophysiology, natural history, diagnostic methods for internal jugular vein thrombosis, and management are discussed.

Necrobacillosis--a resurgence?

Necrobacillosis is a rare life threatening illness caused by Fusobacterium necrophorum. It usually affects previously healthy adolescents and presents as symptomatic pharyngeal infection followed by bacteraemia and metastatic abscesses. A high degree of clinical suspicion is needed because there is often a delay between the presentation of sore throat and the development of systemic illness. The clinical and radiological features of four cases of necrobacillosis are reported and a review of the spectrum of manifestations of metastatic infection presented.

Lemierre's Syndrome

Lemierre's syndrome is characterized by an oropharyngeal infection followed by internal jugular vein septic thrombophlebitis and metastatic emboli, most often to the lungs and joints. The syndrome is most commonly associated with the anaerobic gram-negative rod Fusobacterium necrophorum. Diagnosis is established with evidence of metastatic infection and internal jugular vein thrombophlebitis. CT is considered the diagnostic procedure of choice. Treatment should include an extended course of a beta-lactamase-resistant antibiotic and surgical drainage of any purulent fluid collection. Anticoagulation remains controversial, and ligation of the internal jugular vein is reserved for patients with persistent sepsis and recurrent emboli. With appropriate therapy, mortality is 4% to 12%; but mortality is increased when therapy is delayed.