Blog | Friday, December 14, 2018

Thoughts on a 23-year-old athlete dying from Lemierre Syndrome

K-State football team to honor rower Samantha Scott, who died of Lemierre's Syndrome

Every time I read such a story my heart breaks, a small piece each time. More physicians have become aware of Lemierre syndrome. We must also educate patients and families that sore throats in adolescents and young adults can become life threatening.

Why did she die? The article does not have enough detail to develop a firm conclusion. I can speculate on several reasons from multiple discussions with both survivors and families of adolescents who died. We also have some unpublished survey data that informs my speculations.

What do we know? Fusobacterium necrophorum is the predominant bacteria leading to the syndrome. Dr. Lemierre, in his classic description of the syndrome that now bears his name, noted that patients usually start with a sore throat. Over the next 5 days (or so) the symptoms often get worse, with two major clues, unilateral neck swelling (from the suppurative internal jugular thrombophlebitis) and rigors. In our survey 90% of survivors had rigors prior to diagnosis. We assume that the rigors are a response to bacteremia.

A significant number of survivors did get antibiotics to treat their sore throat. Most report taking azithromycin (a Z-pack). Fusobacterium necrophorum is a gram negative anaerobe that almost always is resistant to azithromycin.

Some patients delay seeking medical care assuming that the “just have a sore throat.” Too many people minimize the concept of sore throats because they generally improve over 3-5 days regardless of antibiotics. Many European countries encourage this strategy, neither testing nor treating any patients with antibiotics.

Just because a strategy works most of the time does not mean that the strategy is preferred. With any strategy we must consider the potential risks and benefits.

Most patients who develop Lemierre Syndrome are aged 15-30. When developing strategies from sore throat patients, we should have different strategies for pre-adolescents, adolescents and older adults. The strategies that apply to pre-adolescents can focus solely on group A strep, but adolescents have at least 3 bacteria causing significant symptoms, group A strep, group C/G strep and Fusobacterium necrophorum. Most experts want to treat group A strep to decrease the probability of acute rheumatic fever. But we believe that the risk of Lemierre Syndrome in adolescent sore throats greatly exceeds the risk of acute rheumatic fever in pre-adolescents or adolescents.

Opponents of targeted empiric antibiotics for adolescent pharyngitis likely overestimate the risks of narrow antibiotics (usually penicillin or amoxicillin) given to approximately 30-40% of adolescents with Centor scores of 3 or 4). We cannot prove that this strategy would prevent all episodes of the syndrome, but it certainly may.

We should continue to stress that while most sore throats are benign and self-resolving, some do lead to suppurative complications. We know that antibiotics decrease peritonsillar abscess without regard to known bacterial etiology.

I likely have a bias towards treating more severe symptoms in adolescents. Articles like the one above harden my position. What would I do if I was seeing adolescent sore throat patients? First I would assess them clinically with the score my colleagues and I developed. If they “look sick” they usually have scores of 3 or 4. Those patients I would treat with a narrow penicillin.

Then I would tell all patients that sore throats should start improving in 24-48 hours and resolve in 3-5 days. If the symptoms are worsening they should come back for further evaluation (both for patients receiving antibiotics and those who do not need antibiotics). I would stress the “red flags,” rigors, unilateral neck swelling and worsening sore throat (over a 3-5 day period). All these red flags should make physicians consider antibiotics, neck CT and blood cultures. If any red flag becomes apparent I would get blood cultures and do a neck CT immediately. If the patient has clinical sepsis, I would immediately started IV antibiotics that should cover anaerobes; some choices would include pip-tazo, penicillin plus metronidazole or clindamycin. If the blood cultures and neck CT are negative then you can likely stop the antibiotics.

The Danish data suggest that in the 15-25 age group 1/70,000 will develop Lemierre Syndrome. Even when patients survive the infection is likely equivalent to endocarditis (or perhaps even worse). We must develop a better strategy for adolescent sore throats. Reading about another death or even another patient who spends a month in the hospital including a week in the ICU for a disease that we might be able to prevent is tragic.

She died and everyone around here is suffering her loss. We must do better.

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.