Methicillin-Resistant Staphylococcus aureus Septic Internal Jugular Thrombophlebitis: Updates in the Etiology and Treatment of Lemierre's Syndrome

Abstract

Background: Lemierre's syndrome is classically precipitated by oropharyngeal infections that progress to suppurative internal jugular vein thrombophlebitis via direct extension. Metastatic pneumonia from septic emboli is nearly universal and bacterial seeding frequently results in disseminated septic foci. Fusobacterium necrophorum is the most commonly reported etiologic agent, though methicillin-resistant Staphylococcus aureus (MRSA) is an emerging pathogen and a myriad of oropharyngeal flora must be covered until blood cultures return. Prompt identification is paramount to minimizing morbidity. Empiric treatment with antibiotics exhibiting predominantly anaerobic activity has been standard, but now may be insufficient, given an evolving microbial landscape. Anticoagulation continues to be debated.

Case report: We describe an uncommon presentation of Lemierre's syndrome in a diabetic patient secondary to MRSA, where the only identifiable source of entry was atraumatic post-auricular cellulitis. Why Should an Emergency Physician Be Aware of This? Given the evolving landscape of organisms implicated in septic internal jugular thrombophlebitis, empiric treatment should entail consideration of MRSA. Patients at an elevated risk include those who are undomiciled or incarcerated, injection drug users, human immunodeficiency virus-positive, and have recently been hospitalized or completed a course of antibiotics. The existing evidence evaluating empiric anticoagulation is low-powered and retrospective and would benefit from randomized controlled trials. Although it does not appear valuable for most, those with thrombus extension, persistent bacteremia, or central venous thrombosis may benefit.

Keywords: Lemierre’s syndrome; MRSA; internal jugular; oropharyngeal infection; septic thrombophlebitis.