Abstract
OBJECTIVE
1) Review presentation, diagnosis, and management of Lemierre syndrome (infectious jugular venous thrombosis). 2) Discuss use of multiplanar reconstruction of contrast CT images to diagnose internal jugular vein (IJV) thrombosis. 3) Learn the indications for obtaining alternative (non-axial) image views and discuss the need for more invasive diagnostic imaging studies such as angiography in detecting IJV thrombosis.
METHOD
This is a case report with a review of the literature. The patient presented in 2009 to the Veterans Administration Medical Center-Memphis and was evaluated as an inpatient by the Otolaryngology Service. Reconstruction of initial CT images provided confirmation of the diagnosis of Lemierre syndrome. A literature search was undertaken to delineate thediagnostic procedures necessary to confirm this diagnosis and direct appropriate management.
RESULTS
A middle-aged male with known poly-substance abuse was admitted to the hospital for agitation and mental status change. He developed fever, painful right neck swelling and trismus on the fifth hospital day. Blood culture was positive for staphylococcus aureus. Contrast-enhanced CT ruled out a deep neck abscess and detected absence of IV contrast at the level of the jugular foramen on axial view. Reconstructed sagittal images delineated a thrombus in the IJV from the jugular foramen to the angle of the mandible, with diffuse soft tissue stranding confirming Lemierre syndrome. Culture-directed IV antibiotics were administered and anticoagulation was instituted.
CONCLUSION
Lemierre syndrome is a rare but potential life-threatening condition with high mortality rate (5%-18%). Diagnosis is made by radiologic finding of thrombosis of internal jugular vein (IJV) with oro-pharyngeal infection typically with fusobacterium necroforum. Variant presentations may involve infections with aerobic organisms like staphylococcus, thrombotic occlusion of internal carotid artery, mastoiditis, otitis media, or sinusitis as a source of infection. The cause of morbidity and death is septic pulmonary emboli, endocarditis or generalized sepsis. This case suggests that advanced imaging using contrast CT with reconstruction in alternate planes may avoid an angiography for the diagnosis of Lemierre syndrome. Communication between the clinician and radiologist is of the essence.