Lemierre's syndrome complicated by cerebral venous sinus thrombosis: A life threatening and rare disease successfully treated with empiric antimicrobial therapy and conservative approach

Abstract

Lemierre's syndrome (LS) is a "forgotten" condition characterized by septic thrombophlebitis of the jugular vein that follows an otolaryngological infection. Fusobacterium necrophorum is the aetiological agent responsible for the syndrome in adolescents and young adults whereas in older people even common bacteria are involved. Complications arise from spreading of septic emboli distally, i.e. to the brain, lungs, bones and internal organs everywhere in the body. We report a middle-aged woman who presented with headache and bilateral sixth cranial nerve palsy following a sphenoidal sinusitis and left mastoiditis. Imaging revealed thrombotic involvement of the left internal jugular vein as well as of several cerebral venous sinuses thrombosis (CVT). Currently, precise management protocols of LS with CVT complication do not exist although a combination of macrolides and second or third-generation cephalosporins, as well as anti-coagulants represent the mainstream of therapeutics. Surgical drainage is associated to remove septic foci but is burdened by severe complications and side effects. Complete recovery was achieved following pharmacological treatment in our patient. This report adds further evidence that LS complicated by CVT may be effectively treated adopting a conservative approach thus avoiding surgical drainage and severe complications.

Keywords: cerebral venous circulation; jugular vein thrombosis; otomastoiditis; sinusitis.

Figure 1.

Initial CT scan of the head enhanced with contrast medium. Thrombosis of the jugular left vein (A) and filing defect of the left sigmoid sinus (B).

Figure 2.

T1 W sequence with gadolinium of transverse head section at the level of pharynx. (A) Filling defect indicating thrombosis at the origin of the left internal jugular vein with hyperintense signal of the surrounding tissue suggestive of inflammatory imbibition (orange arrow). Pseudo-abscess mass diagnosed as parotid adenoma following needle- aspiration (red arrow). Inflammatory solid tissue imprinting the left wall of pharynx (yellow arrow), (B) Filing defect indicating thrombosis of the left sigmoid sinus (red arrow).