Lemierre Syndrome

Anaerobic sepsis after oropharyngeal infection leading to septic thrombophlebitis of the internal jugular vein.

Bacterial infection by gram-negative bacillus Fusobacterium necrophorum (Bacteroides melaninogenicus, Eikenella corrodens, and nongroup A streptococcus have also been isolated from patients with this syndrome) reported in 1936 by Lemierre, who called the syndrome “postanginal septicemia.”

Rare but probably frequently overlooked. Occurs more frequently in teenagers and young adults but has also been described in children.

Not a genetic disorder.

Untreated F. necrophorum tonsillitis or peritonsillar abscess may cause septic thrombophlebitis of the ipsilateral internal jugular vein that rapidly progresses to septicemia because of septic emboli in the lungs or other organs. The proliferation of these bacteria is favored by disruption of normal host mucosal defenses through trauma or hypoxia. Release of proteolytic enzymes, lipopolysaccharide endotoxin, leukocidin, and hemagglutinin accounts for the pathogenicity of F. necrophorum, which usually invades the regional veins. The hemagglutinin moiety can aggregate bovine platelets, and this phenomenon may play a role in the development of internal jugular vein thrombosis.

Cervical Doppler ultrasound shows thrombophlebitis of the internal jugular vein, and high-resolution CT scanning shows nodules abutting the pleura with or without cavitation. Positive blood cultures for F. necrophorum confirm the diagnosis.

Fever and neck pain; moderate dyspnea; pharyngotonsillar inflammation and ipsilateral tender swelling of the cervical region; often complicated by distant metastatic infections; chest radiograph usually shows ill-defined infiltrates or round opacities but also signs of septic lung emboli (wedge-shaped peripheral densities, nodular or cavitary lesions). Overall mortality rate approximately 15% (but > 80% if no antibiotics are given).

Check room air pulse oximetry and chest radiograph. Appropriate antibiotic treatment should have been started. If central venous catheterization is foreseen, ultrasound examination of the jugular and subclavian vessels must be obtained to check the potency of these vessels.

All anesthetic considerations for management of anesthesia of a septic patient with pulmonary ventilation/perfusion mismatch and potential cardiovascular instability must be clearly established and considered in designing the anesthetic plan.

No known specific pharmacological implications; however, patients treated by antibiotics and, occasionally, by anticoagulants, which occasionally interfere with other treatments, may affect anesthetic agents and techniques. For instance, the use of antibiotics may significantly affect the pharmacokinetics of neuromuscular blockade agents.

Grisel Syndrome: Infectious complication of upper neck inflammatory processes (pharyngitis and pharyngeal abscess) and head and neck surgery resulting in subluxation of the atlantoaxial joint.