Home > Case of the Week

Title : A 65-year old female w/ neck pain
Date : December 12, 2008
Contributed by

Mi Kyong Joung, M.D., Hae Suk Cheong, M.D. Samsung Medical Center, Seoul, Korea

Patient History
Age/Sex 65/F
Chief complaint Neck pain
Present illness

Five weeks before admission, she had toothache without any dental procedure. Three weeks before admission, she developed fever,headache,neck pain and neck swelling. Two weeks before admission, she visited tertiary university hospital and neck CT was done. Myositis and diffuse thrombus of left internal jugular vein were diagnosed. The patient was prescribed antibiotics (vancomycin, augmentin and clindamycin). On the third hospital day, Streptococcus viridans was isolated on the blood which performed on the admission day.

Past medical history

Diabetes mellitus (+) HTN (-) Hepatitis (-) Tuberculosis (-)

Physical examination

Initial vital sign : 137/94 mmHg – 78/min – 20/min – 36.7 Alert mental state Neck stiffness (-) Left neck tenderness/redness/local heatness (+/+/+) Chest – clear breath sound on both lung field regular heart beat without murmur Abdomen – tenderness (-), palpable mass (-)

Initial laboratory findings

CBC 5550> 14.3<344K AST/ALT 38/18 BUN/Cr 5.1/0.4 ESR/CRP 83/6.4 UA - clear

Neck CT on admission day

Question - ID Case of the Week ( December 12, 2008 )
Q1. What would be the diagnosis ? Q2. What would be the most common cause of pathogen?
Correct Answer

Q1.Diagnosis : Lemierre syndrome

Q2.Most common pathogen : Fusobacterium necrophorum


# Lemierre syndrome 

- Definition : syndrome characterized by an oropharnx infection, which causes a
                   septic thrombophlebitis of the internal jugular vein and therefore a
                   metastatic infection.

- First report : In 1936, Lemierre with a publication of 20 cases, 18 of them died.

- Pathogen :
   . Most common - Fusobacterium necrophorum (81.7% of cases)
   . 10.1% of the cases a mixed infection ( with bacteroides fragilis, Staphylococcus
      epidermidis, Enterococcus sp....)

  . Incidence : between 0.6 and 2.3 million population
  . Male to female ratio of approximately 2:1
  . Most commonly in teenagers and young adults, but can also affect other age groups
  . Mortality : 4 ~ 18%

  . Involvement of the internal jugular vein occurs by direct extension through the 
    fascial plane between the tonsils and the parapharyngeal space or by
    hematogenous or lymphatic spread from peritonsilar vessels 
  . Once thrombophlebitis of the internal jugular vein occurs, septic emboli can arise
    and spread to distant sites and organs

-Clinical features
  . Clinical symptoms depends on the primary infection
  . Mostly presented by fever in 82%
  . Cervical lymphadenopathy of anterior triangle
  . Tender,usually unilateral, swelling at the angle of the jaw, or anterior and parallel
    with the sternomastoid muscle
  . Pain, odynophagia,trismus,vomit,nausea

  . The diagnosis of Lemierre syndrome can be made only of the clinician is aware of
    the existence of the disease
  . Radiologic diagnosis : confirm the internal jugular vein thrombosis can be
       accomlished by ultrasonography, contrast CT scan, or MRI
  . Laboratory diasnosis of pathogen.

  . Surgical drainage as well as directing appropriate antimicrobial therapy
  . Peniciilin and metronidazole is consideredx a the first option treatment
  . Antibiotic therapy is usually given for a period of 3 to 6 weeks. There are no 
    recommended for the duration of treatment because the clinical course of the
    disease is so variable.

  . Pulmonary involvement : through hematogenous way septic embolus it gives off and
    metastasize more commonly in the lungs (79.8%). The chest X-ray shows a 
    pulmonary infiltrate in lack of cavitations
  . Bone and joint involvement : second most common, ranging from arthralgia and
    septic arthritis to osteomyelitis
  . Skin and soft tissue lesions, mainly in the form of abscesses
  . Liver abscess and splenic abscess. 



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