Correspondence

Hematogenous Anaerobic Osteomyelitis

N Engl J Med 2002; 347:533August 15, 2002

Article

To the Editor:

The April 4 Image in Clinical Medicine by Bhatti and Seville1 is of a man with hematogenous anaerobic osteomyelitis. We would like to add that the combination of a dental infection with fusobacterium and subsequent systemic spread is suggestive of Lemierre's syndrome.

In 1936, Lemierre described 20 patients with “anaerobic septicemia,” 18 of whom died.2 Lemierre's syndrome is characterized by a primary infection of the oropharynx in a young, previously healthy person that results in septic thrombophlebitis of the ipsilateral internal jugular vein with fever and disseminated metastatic abscesses. The syndrome occurs in children with otitis media, in young adults with pharyngotonsillitis, in adults with tooth infections, and in patients of all ages with other foci (e.g., mastoiditis or sinusitis).3,4 The main pathogen is Fusibacterium necrophorum, an anaerobic, gram-negative rod. The recommended antibiotic regimen is a combination of high-dose penicillin and metronidazole or clindamycin monotherapy for two to six weeks. In the era before antibiotics, the mortality rate was very high, and even now, it is as high as 17 percent. Bhatti and Seville did not mention whether their patient had pain in the neck, representing thrombophlebitis of the internal jugular vein; however, this symptom may be absent or misinterpreted.5

Lemierre's syndrome may be referred to as the “forgotten disease” because it is rare, but it may also be underdiagnosed. We believe that thrombophlebitis of the internal jugular vein, as described by Lemierre, is an important pathophysiological event in the development of metastatic abscesses.

Gerald H.A. Staaks, M.D.
Frans H. Krouwels, M.D., Ph.D.
Bibi H.B. Kwa, M.D., Ph.D.
Onze Lieve Vrouwe Hospital, 1090 HA Amsterdam, the Netherlands
g.h.a.staaks@olvg.nl

5 References

1. 1

   Bhatti MA, Seville MTA. Hematogenous anaerobic osteomyelitis. N Engl J Med 2002;346:1060-1060
   Full Text | Web of Science | Medline

2. 2

   Lemierre A. On certain septicaemias due to anaerobic organisms. Lancet 1936;40:701-703
   CrossRef

3. 3

   Hagelskjaer Kristensen L, Prag J. Human necrobacillosis, with emphasis on Lemierre's syndrome. Clin Infect Dis 2000;31:524-532
   CrossRef | Web of Science | Medline

4. 4

   Gudinchet F, Maeder P, Neveceral P, Schnyder P. Lemierre's syndrome in children: CT and color Doppler sonography patterns. Chest 1997;112:271-273
   CrossRef | Web of Science | Medline

5. 5

   Screaton NJ, Ravenel JG, Lehner PJ, Heitzman ER, Flower CDR. Lemierre syndrome: forgotten but not extinct -- report of four cases. Radiology 1999;213:369-374
   Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Staaks and colleagues raise the possibility of Lemierre's syndrome in our patient. This diagnosis was considered, but we believed that the patient did not have the classic signs and symptoms of Lemierre's syndrome. Patients with this disease are typically described as having an acute sepsis syndrome with shaking chills, spiking fevers, and profound prostration and neck swelling and tenderness within a week after the primary local infection; the rate is 17 percent mortality.1,2 Our patient had a protracted course in which the onset of illness was two months after the initial dental abscess, and he presented to the hospital four months after the odontogenic infection with signs and symptoms of a chronic infection, rather than acute sepsis. He did not report neck pain, and there were no signs of thrombosis of the internal jugular vein. No specific tests to diagnose internal-jugular-vein thrombosis were conducted, however, and as has been reported previously,3 the signs and symptoms of thrombophlebitis may be subtle or absent, and thus, this finding may be identified only with the use of specific radiologic tests or at autopsy.3

Maria Teresa A. Seville, M.D.
Aurora BayCare Medical Center, Green Bay, WI 54308-8900
teresa.seville@aurora.org

Maqsood A. Bhatti, M.D.
King Faisal Specialist Hospital and Research Center, 21499 Jeddah, Saudi Arabia

3 References

1. 1

   Lemierre A. On certain septicaemias due to anaerobic organisms. Lancet 1936;1:701-703
   CrossRef | Web of Science

2. 2

   Hagelskjaer Kristensen L, Prag J. Human necrobacillosis, with emphasis on Lemierre's syndrome. Clin Infect Dis 2000;31:524-532
   CrossRef | Web of Science | Medline

3. 3

   Screaton NJ, Ravenel JG, Lehner PJ, Heitzman ER, Flower CDR. Lemierre syndrome: forgotten but not extinct -- report of four cases. Radiology 1999;213:369-374
   Web of Science | Medline