Lemierre's Syndrome and Defensive Antibiotic Prescribing Tactics: Lessons to Be Had

A 14-year-old girl with an unremarkable medical history was admitted to hospital with signs and symptoms of septicemia. Ten days prior to her admission she had complained of a sore throat and was seen by her general practitioner. A clinical diagnosis of tonsillitis was made, and in view of an unconfirmed previous allergic reaction to penicillin, erythromycin was prescribed. Despite the treatment, the patient remained unwell, developing pyrexia, rigors, chest and abdominal pain, and diarrhea. On hospital admission, she presented with a fever of 38.9°C (102°F), tachycardia, right-sided expiratory wheezing, and mild abdominal tenderness; however, the tonsillitis had resolved. A blood count at this time showed leukocytosis with neutrophilia (leukocytes, 15.6 × 10/L; neutrophils, 14.6 × 10/L) and markedly elevated (>200 mg/L) C-reactive protein. A chest X ray was unremarkable. Blood cultures were taken, and intravenous antibiotic therapy was initiated. In view of concerns regarding the reported though unconfirmed allergy to penicillin, cefuroxime was the antibiotic of choice. By the end of the first day in the hospital, the patient’s condition had deteriorated and she required overnight oxygen administration. Lemierre’s syndrome, also known as necrobacillosis, is a rare though potentially fatal systemic anaerobic bacterial infection that is usually associated with Fusobacterium necrophorum. The syndrome is characterized by an underlying oropharyngeal infection, with evidence of septic thrombophlebitis exhibited by positive blood cultures, clinical or radiographic confirmation of internal jugular vein thrombosis, and at least 1 distal metastatic focus. With the introduction and widespread use of penicillin in the early part of the 20th century, Lemierre’s syndrome dramatically decreased, and during the 1960s and 1970s few reports appeared in the literature. Over the past few decades, however, there has been a gradual reemergence of this condition. In an effort to inform physicians of this changing trend and increase their awareness of Lemierre’s syndrome, a number of authors have reported their clinical experiences. In a further effort toward this end, we present a case of Lemierre’s syndrome in a 14-year-old girl who was admitted to hospital 10 days after a throat infection. Of particular interest is the fact that our patient was treated initially with erythromycin for her throat infection, an antibiotic unsuitable for fusobacterial infections, because she was thought to be allergic to