Case of the Week
Section Editors: Matylda Machnowska1 and Anvita Pauranik2
1University of Toronto, Toronto, Ontario, Canada
2BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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December 15, 2016
Otogenic Septic Jugular Vein Thrombophlebitis (Lemierre’s Syndrome) with s. pyogenes bacteremia
- Background:
- Septic jugular vein thrombophlebitis is a life-threatening complication of head and neck infections. It is seen most frequently in tonsillar infection and less frequently in otogenic, sinusal, dental, and meningeal infections.
- Mortality rate is considerable, ranging from 0-18% in recent literature. Prognosis depends mainly on the local extent of disease and the presence of associated septic embolic disease.
- Clinical Presentation:
- Patients commonly present with a head and neck infection (mainly tonsilitis, more rarely otitis media or other infections) and cervical tenderness and swelling.
- If untreated, they may present to the ER with disseminated disease, most commonly lung infection and empyema. Diagnosis is often mistaken for bacterial endocarditis.
- Early diagnosis is key due to the potential complications and the importance of early antibiotic treatment.
- Key Diagnostic Features:
- Diagnosis is based on the identification of the infection focus and associated internal jugular vein thrombosis.
- The study should be completed with CT to look for septic pulmonary, splenic, and/or renal emboli. Clinical assessment looking for other signs of distal emboli, including fundoscopic exam, should be conducted.
- Differential Diagnoses:
- Nonseptic jugular thrombosis: there would be a jugular filling defect without associated inflammatory changes, abscess formation, and no intravascular air bubbles.
- Lung infection should be differentiated from lung metastases, primary infection, or septic embolisms from other source (e.g., septic endocarditis).
- Neoplastic disease may be difficult to differentiate from septic pulmonary emboli, especially if pulmonary nodules are small.
- Septic endocarditis may have little or no imaging translation and is principally a clinical diagnosis.
- Treatment:
- Prompt initiation of wide-spectrum antibiotic therapy that covers anaerobes and β-lactamase-resistant organisms
- Surgical drainage of the abscesses may be necessary.
- Anticoagulation is controversial and should be discussed on a case-to-case basis.
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