Lemierre's Syndrome and Pharyngitis

Abstract & Commentary

By Mary Elina Ferris, MD, Clinical Associate Professor, University of Southern California. Dr. Ferris reports no financial relationship to this field of study.

Synopsis: Fusobacterium necrophorum causes pharyngitis just as often as group A beta-hemolytic streptococcus in adolescents and young adults, and can result in the life-threatening Lemierre's syndrome. Macrolides should be avoided when this pathogen is suspected.

Source: Centor RM. Expand the pharyngitis paradigm for adolescents and young adults. Ann Intern Med 2009;151: 812-815.

A gram-negative anaerobe is being increasingly identified as a common cause of pharyngitis in adolescents and young adults, with the potential to cause serious suppurative complications and even death. Fusobacterium necrophorum has been identified in up to 10% of pharyngitis cases in 15- to 24-year-olds, which is comparable to the incidence of group A beta-hemolytic streptococcus.1 This bacterium has the potential to cause a syndrome, occurring approximately 4 days after initial improvement, of bacteremia and thrombophlebitis of the internal jugular vein, first described in 1936 by Lemierre. At that time, mortality was 90%, and now, even with modern treatment, recent case series suggest 5% mortality with at least 10% sustaining permanent sequelae.

Clinical presentation of this type of pharyngitis includes worsening symptoms without resolution after 3-5 days, and neck pain or swelling, especially unilateral. There may be bacteremic symptoms such as rigors, chills, or night sweats. Septic emboli can occur, particularly to the lungs. Unfortunately there is no simple option for identifying this pathogen other than blood cultures; special media is required and no commercial polymerase chain reaction tests are available. Early treatment with penicillin or a cephalosporin, not a macrolide, leads to better outcomes. When bacteremia is suspected, clindamycin or penicillin, combined with metronidazole, is indicated.

Current treatment guidelines for pharyngitis focus on prevention of rheumatic fever from group A beta-hemo-lytic streptococcus, which in the United States occurs in < 10 cases/100,000 patients; 10% of those have complicated disease, and 1% die.2 Hypothetically, the incidence of Lemierre's syndrome could be much greater, based on estimates of 250 cases/100,000 adolescents. For persistent pharyngitis symptoms, the differential diagnosis includes peritonsillar abscess; Lemierre's syndrome; group A, C, or G streptococcal pharyngitis; infectious mononucleosis; and acute HIV infection. Clinicians should be alert to the potential presence of these other pathogens in adolescents and young adults, and treat aggressively when symptoms persist longer than expected.

Commentary

After we encountered a case of Lemierre's syndrome at our college Student Health Service that was almost fatal to an otherwise healthy graduate student, we have definitely had a heightened awareness that a "sore throat" can be more than a minor illness. A recent Danish study found more Fusobacterium necrophorum than group A beta-hemolytic streptococcus in admissions for peritonsillar abscess (23% vs 17% in 847 patients).3

These patients were younger and had higher neutrophil counts and C-reactive protein values.

Probably the most important pearl for clinicians is to realize that macrolide antibiotics will not treat this bacterium; penicillins and cephalosporins are the drugs of choice, with addition of clindamycin or metronidazole when sepsis is suspected. Although the Infectious Disease Society of America guidelines for pharyngitis currently recommend antibiotic treatment only for positive streptococcus test results,4 concern about Fusobacterium necrophorum led these authors to suggest non-macrolide antibiotic treatment for pharyngitis in young adults regardless of test results if at least three of the following are present: fever history, tonsillar exudates, swollen tender anterior cervical adenopathy, or lack of cough.

References

1. Amess JA, et al. A six-month audit of the isolation of Fusobacterium necrophorum from patients with sore throat in a district general hospital. Br J Biomed Sci 2007;64:63-65.

2. Neuner JM, et al. Diagnosis and management of adults with pharyngitis. A cost-effectiveness analysis. Ann Intern Med 2003;139:113-122.

3. Ehlers Klug T, et al. Fusobacterium necrophorum: Most prevalent pathogen in peritonsillar abscess in Denmark. Clin Infect Dis 2009;49:1467-1472.

4. Bisno AL, et al. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America. Clin Infect Dis 2002;35:113-125.