Lemierre’s syndrome

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Case information

A 17-year-old boy presented with acute onset right-sided facial swelling, trismus, pharyngitis, and sepsis. CT soft tissue neck and CT chest were obtained (see below)1.

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  • Fig 1. CT soft tissue neck with contrast: Axial images from CT soft tissue neck with contrast demonstrating an abscess (arrow in A) in the right parapharyngeal space and an enhancing non-occlusive thrombus (arrow in B) in a small vein draining into the right internal jugular vein with vascular wall enhancement.
  • Fig 2. CT chest with contrast (on the day of admission): Images from CT chest demonstrating large pulmonary nodules with spiculated margins and some with central cavitation (arrows).
  • Fig 3. MRI brain with and without contrast (one day after admission): Diffusion-weighted imaging (uppercase) and apparent diffusion coefficient (lowercase) demonstrating multiple acute/subacute infarcts in the right medial temporal lobe (black arrow in image A), anteromedial aspect of the right cerebellum (white arrow in image A), and dorsolateral aspect of the right brainstem (arrow in image B). Also note soft tissue swelling on the right side of the face (arrows in images b and c).
  • Fig 4. MR angiogram, MRI brain, and MR venogram (one day after admission): (A) 3D time-of-flight MR angiogram demonstrating diffuse narrowing of the right internal carotid artery (white arrow). (B) Post-contrast T1 fat saturated image demonstrating prominent, abnormal enhancement along the wall of the petrous segment of right internal carotid artery (white arrow) and prominent meningeal and parenchymal enhancement is also seen along the adjacent temporal lobe (black arrow). (C) Post-contrast T1 fat saturated image revealing abnormal thick dural enhancement at the medial aspect of the right middle cranial fossa and the right tentorium (black arrow) and swelling and enhancement of the right temporalis muscle along with the overlying soft tissue (white arrow). (D) MR Venogram demonstrating central filling defect within the right sigmoid sinus (white arrow) in keeping with non-occlusive thrombus.
  • Fig 5. Brain MRI (eight days after admission): (A) T2 weighted image demonstrating soft tissue swelling on the right face, right sided proptosis, and a parenchymal lesion at the medical aspect of the right temporal lobe in keeping with an early abscess. (B and C) Post contrast T1 image and DWI demonstrating right medial temporal lobe abscess.
  1. Differential diagnosis
  • Jugular vein thrombosis
  • Lemierre’s syndrome
  • Lung metastases
  • Cervical lymphadenitis

  1. Diagnosis: Lemierre’s syndrome

  2. Treatment: The patient was treated with antibiotics and anticoagulation for six weeks. During this time, the patient demonstrated improvement in serial neurological examinations and participated in multidisciplinary rehabilitation. At six weeks, the patient was able to follow commands and had slight improvement in left upper extremity weakness but still displayed dense left lower extremity hemiplegia. The patient was discharged after 13 weeks with significant neurological deficits including: moderate dysarthria, left upper extremity weakness, and inability to independently ambulate secondary to left lower extremity hemiplegia.

Lemierre’s syndrome

Lemierre’s syndrome typically begins with an oropharyngeal infection that develops into septic thrombophlebitis of the internal jugular vein within a few weeks.

  • The infection spreads locally into the lateral pharyngeal space, invading the internal jugular vein and causing septic thrombophlebitis (infected blood clots).
  • Septic emboli from the thrombus then disseminate via the bloodstream, leading to metastatic infections in distant organs, most commonly the lungs (97% of cases), followed by joints, liver, spleen, and central nervous system.

The primary causative agent is Fusobacterium necrophorum, a bacterium naturally present in the oropharyngeal microbiota. Complications resulting from septic embolization most frequently affect the lungs, occurring in up to 97% of cases, with large joints being the next most common site. Less frequently observed manifestations involve osteomyelitis, endocarditis, pericarditis, or abscesses in organs such as the liver, spleen, or kidneys. While the syndrome primarily localizes to the internal jugular vein, extension into adjacent arteries is rare, reported in only 7.7% of cases. Central nervous system complications, though uncommon, may encompass brain abscesses, epidural abscesses, meningitis, subdural empyema, cerebral venous thrombosis, or strokes.

  1. Brandon Simons, Mason Williams, Laura Hayes, Kanika Gupta, Tushar Chandra, Lemierre’s syndrome presenting with arterial and Central nervous system involvement, BJR|Case Reports, Volume 10, Issue 4, July 2024, uaae026, https://doi.org/10.1093/bjrcr/uaae026 ↩

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