This article has an interesting perspective on Lemierre's and strep
Annals of Internal Medicine
December 1, 2009
vol. 151 no. 11 812-815
Expand the Pharyngitis Paradigm for Adolescents and Young Adults
Robert M. Centor, MD
From the University of Alabama at Birmingham, Huntsville, Alabama.
Current guidelines and review articles emphasize that clinicians
should consider group A ?-hemolytic streptococcus in the diagnosis and
management of patients with acute pharyngitis. Recent data suggest
that in adolescents and young adults (persons aged 15 to 24 years),
Fusobacterium necrophorum causes endemic pharyngitis at a rate similar
to that of group A ?-hemolytic streptococcus. On the basis of
published epidemiologic data, F. necrophorum is estimated to cause the
Lemierre syndrome?a life-threatening suppurative complication?at a
higher incidence than that at which group A streptococcus causes acute
rheumatic fever. Moreover, these estimates suggest greater morbidity
and mortality from the Lemierre syndrome. The diagnostic paradigm for
adolescent pharyngitis should therefore be expanded to consider F.
necrophorum in addition to group A streptococcus. Expanding the
pharyngitis paradigm will have several important implications. Further
epidemiologic research is needed on both F. necrophorum pharyngitis
(especially clinical presentation) and the Lemierre syndrome.
Clinicians need reliable diagnostic techniques for F. necrophorum
pharyngitis. In the meantime, adolescents and young adults who develop
bacteremic symptoms should be aggressively treated with antibiotics
for F. necrophorum infection. Physicians should avoid macrolides if
they choose to treat streptococcus-negative pharyngitis empirically.
Finally, pediatricians, internists, family physicians, and emergency
department physicians should know the red flags for adolescent and
young adult pharyngitis: worsening symptoms or neck swelling
(especially unilateral neck swelling). Adolescent and young adult
pharyngitis is more complicated than previously considered.
David F. Soglin, M.D.
Chairman, Department of Pediatrics
John H. Stroger, Jr. Hospital of Cook County (Cook County Hospital)
Cook County Health and Hospitals System
1900 W Polk Suite 1100
Chicago, IL 60612
Quoting "STEPHEN M JOHNSON" <[log in to unmask]>:
> Lemierre's syndrome - septic thrombophlebitis of the internal
> jugular vein, usually caused by anaerobic GNR Fusobacterium
> necrophorum, though can be polymicrobial. Usually previously well
> teen with sore throat, strep, mono or other, starts to get better
> then worsens with unilateral neck pain, tenderness along SCM, looks
> ill, may have cough with septic emboli to lungs or CNS
> complications. Usually do not have big visible cervical adenitis,
> so you have to suspect it by unilateral pain, tenderness and ill
> appearance. Here's a pearl: if you suspect it, an adult-type set
> of aerobic and anaerobic blood cultures may be better than the
> standard peds aerobic BC. Have seen one! - Susan Omurathe
> Children's Hospital at LEgacy EmanuelPortland, OR
>> Date: Sun, 23 Jan 2011 20:52:37 -0500
>> From: [log in to unmask]
>> Subject: Amazing case..did you have one of those?
>> To: [log in to unmask]
>> A 7 year old Child, recent immigrant from eastern Europe presented with 4
>> days of right neck swelling.
>> He was seen by his PMD 2 days prior had a throat culture which was positive
>> for strep and discharge on amoxil.
>> In our ER he was afebrile, had a very hard slightly erythematous, tender
>> mass starting behind his right ear, going down his right neck.
>> He also had a stiff neck, holding it straight up. The rest of the exam was
>> I assumed he had staph/strep lymphadenitis and we debated whether IV Clinda
>> in the ER with next day follow up is OK or maybe we should admit him.
>> We then did an ultrasound which showed multi loculated abscesses, on
>> sitting very close to the right carotid artery.
>> Worried about the location of this abscess we did a neck CT (with
>> contrasrt) which confirmed the presence and location of the abscess
>> but also showed
>> a right internal jugular vein totally clotted from the bifurcation (with
>> the subclavian) to the level of the angle of C2. The child was obviously
>> admitted and is being treated (Lemierre's syndrome ?).
>> Now, I have seen zillion children with large cervical lymphadenitis, I do
>> not use ultrasound on many ( we had none until a few years ago...) and
>> certainly do not CT their neck routinely.
>> And now I am asking myself, did I miss those cases before, was I just
>> lucky that no one ended up septic, I was certainly lucky here!
>> did any one of you have a similar case?
>> Giora Winnik MD
>> Maimonides MC, Brooklyn NYC
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