Acute pediatric potentially thrombogenic craniocervical infections: A consecutive series of Lemierre and Lemierre-like syndrome cases

Abstract

Background: Major venous thrombophlebitis and/or thrombosis in association with acute head and neck infection is a serious but uncommon event. The action of specific bacterial toxins causes the thrombophlebitis, which has the propensity of systemic complications and local circulatory effects. Lemierre's syndrome (LS) is a specific entity within this group, often caused by the anaerobe Fusobacterium necrophorum (FN). Objective: Review of six consecutive pediatric cases and a critical revision of diagnostic categories. Setup: Tertiary referral center. Study design: Case series of pediatric craniocervical infections complicated by internal jugular vein thrombophlebitis (IJVT). Demographics, record of anti-thrombosis management, imaging, and antimicrobial management, duration of admission, clinical picture and sequelae were retrospectively collected. Results: Six cases (three girls and three boys; age range from 7 to 16 years old) were identified over a period of 3 years. One case was a certain LS; four were probable LS cases and one possible diagnosis. Six children had IJVT diagnosed on imaging, which also demonstrated embolic seeding to the knee on one occasion and to the ankle in another. Anti-thrombosis management as outpatients was instituted for 3 months in five out of the six. None had permanent sequelae except one (unilateral high tone sensory hearing loss). In four cases, the duration of admission was 10 days or less, whereas the other two cases stayed for 2 and 5 weeks, respectively. Conclusions: Thrombogenic head and neck infections may occur in children more readily than currently believed. Failure to detect the characteristic anaerobe and the low index of suspicion of IJVT may contribute to missing cases. Modern imaging modalities represent a window of opportunity to detect the key pathogenic process to arguably the most morbid event, namely the IJVT. By incorporating their findings from the outset, the disease is categorized and its devastating complications prevented.