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
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
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
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.
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Hoehn S, Dominguez TE: Lemierre's syndrome: An unusual cause of sepsis and
abdominal pain. Crit Care Med
Klinge L, Vester U, Schaper J, Hoyer PF: Severe Fusobacteria infections
(Lemierre syndrome) in two boys. Eur J Pediatr