Internal and Emergency Medicine | 2019
Lemierre’s syndrome: a possible cause of neck pain
Abstract
A 55-year-old previously healthy woman presented to the emergency department with a 2-day history of right neck pain. She also suffered from right ear pain with otorrhea in recent 1 week. On physical examination, she had swelling and erythema on the right neck with purulent discharge from the right ear and perforation of the eardrum. Laboratory data revealed elevated white blood cell count (20.3 × 103/ μL) and C-reactive protein level (328.4 mg/L). Point-ofcare ultrasound of the neck revealed intraluminal echogenic material and absence of color Doppler flow over the right internal jugular vein (Fig. 1a, b and Video 1). Computed tomography (CT) with contrast was obtained subsequently to confirm venous thrombosis in the right internal jugular vein (Fig. 1c). Lemierre’s syndrome secondary to right otitis media was impressed. The culture of right ear discharge revealed mixed infection with Staphylococcus aureus and Providencia stuartii. After a course of antibiotic therapy, the patient was asymptomatic at discharge 7 days later. Lemierre’s syndrome, septic thrombophlebitis of the internal jugular vein, is caused by adjacent infection, such as tonsil, larynx, pharynx, chest and even middle ear [1]. In the post-antibiotic era, Lemierre’s syndrome is a rare condition with an incidence of 3.6 cases per million people per year [2]. The overall mortality rate was around 2–5% in recent studies [1, 3]. The majority of offending micro-organisms were Fusobacterium species, followed by Streptococci, Staphylococcus aureus and other miscellaneous Gram-negative bacteria [3]. The discovery of jugular vein thrombus is crucial to make the diagnosis. Ultrasound is recommended as the initial method of diagnostic imaging, which demonstrates an echogenic material in the jugular vein with absent Doppler flow [4]. Contrast-enhanced CT is subsequently used for a definitive diagnosis. Treatment of Lemierre’s syndrome depends on the severity of the disease, ranging from antibiotic therapy to surgical drainage of primary source. The role of anticoagulation remains controversial [1, 3].