Lemierre Syndrome

Authors: William F. Wright, DO, MPH, Christine N. Shiner, PharmD, Julie A. Ribes, MD, PhD


Lemierre’s syndrome is an uncommon complication of pharyngitis in the United States and caused most commonly by the bacterium Fusobacterium necrophorum. The syndrome is characterized by a history of recent pharyngitis followed by ipsilateral internal jugular vein thrombosis and metastatic pulmonary abscesses and is a disease for which patients will seek medical care and advice. As most patients are admitted to the hospital under internal medicine, practitioners should be familiar with the usual signs and symptoms of Lemierre’s syndrome along with its diagnosis and treatment. Controversy involves the choice and duration of antimicrobial therapy used for treatment and anticoagulation therapy for internal jugular vein thrombosis. As the diagnosis and management of this syndrome has generated controversy, an updated review of the literature and treatment recommendations may be helpful for providing optimal care for patients with this often unrecognized and confusing infection.

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. Hagelskjaer Kristensen L, Prag J. Human necrobacillosis, with emphasis on Lemierre’s syndrome. Clin Infect Dis 2000; 31: 524–532.
2. Riordan T, Wilson M. Lemierre’s syndrome: more than a historical curiosa. Postgrad Med J 2004; 80: 328–334.
3. Chirinos JA, Lichenstein DM, Garcia J, et al. The evolution of Lemierre syndrome: report of 2 cases and review of the literature. Medicine (Baltimore) 2002; 81: 458–465.
4. Riordan T. Human infection with Fusobacterium necrophorum (necrobacillosis), with a focus on Lemierre’s syndrome. Clin Microbiol Rev 2007; 20: 622–659.
5. Karkos PD, Asrani S, Karkos CD, et al. Lemierre’s syndrome: a systematic review. Laryngoscope 2009; 119: 1552–1559.
6. Lemierre A. On certain septicaemias due to anaerobic organisms. Lancet 1936; ii: 601–703.
7. Vogel LC, Boyer KM. Metastatic complications of Fusobacterium necrophorum sepsis. Two cases of Lemierre’s postanginal septicemia. Am J Dis Child 1980; 134: 356–358.
8. Seidenfeld SM, Sutker WL, Luby JP. Fusobacterium necrophorum septicemia following oropharyngeal infection. JAMA 1982; 248: 1348–1350.
9. Shannon GW, Ellis CV, Stepp WP. Oropharyngeal Bacteroides melaninogenicus infection with septicemia: Lemierre’s syndrome. J Fam Pract 1983; 16: 159–160, 163, 166.
10. Moore B, Dekle C, Werkhaven J. Bilateral Lemierre’s syndrome: a case report and literature review. Ear Nose Throat J 2002; 81: 234–236, 238–240, 242.
11. Hagelskjaer LH, Prag J, Malczynski J, et al. Incidence and clinical epidemiology of necrobacillosis, including Lemierre’s syndrome, in Denmark 1990–1995. Eur J Clin Microbiol Infect Dis 1998; 17: 561–565.
12. Hagelskjaer Kristensen L, Prag J. Lemierre’s syndrome and other disseminated Fusobacterium necrophorum infections in Denmark: a prospective epidemiological and clinical survey. Eur J Clin Microbiol Infect Dis 2008; 27: 779–789.
13. Ramirez S, Hild TG, Rudolph CN, et al. Increased diagnosis of Lemierre’s syndrome and otherFusobacterium necrophorum infections at a children’s hospital. Pediatrics 2003; 112: e380–e385.
14. Brazier JS, Hall V, Yusuf E, et al. Fusobacterium necrophorum infections in England and Wales 1990–2000. J Med Microbiol 2002; 51: 269–272.
15. Venglarcik J. Lemierre’s syndrome. Pediatr Infect Dis J 2003; 22: 921–923.
16. Weeks DF, Katz DS, Saxon P, et al. Lemierre syndrome: report of five new cases and literature review. Emerg Radiol 2010; 17: 323–328.
17. Chacko EM, Krilov LR, Patten W, et al. Lemierre’s and Lemierre’s-like syndromes in association with infectious mononucleosis. J Laryngol Otol 2010; 124: 1257–1262.
18. Ridgway JM, Parikh DA, Wright R, et al. Lemierre syndrome: a pediatric case series and review of literature. Am J Otolaryngol 2010; 31: 38–45.
19. Bondy P. Lemierre’s syndrome: what are the roles of anticoagulation and long-term antibiotic therapy? Ann Otol Rhinol Laryngol 2008; 117: 679–683.
20. Tan ZL, Nagaraja TG, Chengappa MM. Fusobacterium necrophorum infections: virulence factors, pathogenic mechanism and control measures. Vet Res Commun 1996; 20: 113–140.
21. Brazier JS. Human infections with Fusobacterium necrophorum. Anaerobe 2006; 12: 165–172.
22. Forrester LJ, Campbell BJ, Berg JN, et al. Aggregation of platelets by Fusobacterium necrophorum. J Clin Microbiol 1985; 22: 245–249.
23. Kikkert R, Laine ML, Aarden LA, et al. Activation of toll-like receptors 2 and 4 by gram-negative periodontal bacteria. Oral Microbiol Immunol 2007; 22: 145–151.
24. Liu H, Redline RW, Han YW. Fusobacterium nucleatum induces fetal death in mice via stimulation of TLR4-mediated placental inflammatory response. J Immunol 2007; 179: 2501–2508.
25. Razonable RR, Rahman AE, Wilson WR. Lemierre syndrome variant: necrobacillosis associated with inferior vena cava thrombosis and pulmonary abscesses after trauma-induced leg abscess. Mayo Clin Proc 2003; 78: 1153–1156.
26. Friberg N, Carlson P, Kentala E, et al. Factor H binding as a complement evasion mechanism for an anaerobic pathogen, Fusobacterium necrophorum. J Immunol 2008; 181: 8624–8632.
27. Holm K, Frick IM, Bjorck L, et al. Activation of the contact system at the surface of Fusobacterium necrophorum represents a possible virulence mechanism in Lemierre’s syndrome. Infect Immun 2011; 79: 3284–3290.
28. Tarnvik A. Anaerobic meningitis in children. Eur J Clin Microbiol 1986; 5: 271–274.
29. Screaton NJ, Ravenel JG, Lehner PJ, et al. Lemierre syndrome: forgotten but not extinct—report of four cases. Radiology 1999; 213: 369–374.
30. Nguyen-Dinh KV, Marsot-Dupuch K, Portier F, et al. Lemierre syndrome: usefulness of CT in detection of extensive occult thrombophlebitis. J Neuroradiol 2002; 29: 132–135.
31. Kowalsky SF, Echols RM, McCormick EM. Comparative serum bactericidal activity of ceftizoxime/metronidazole, ceftizoxime, clindamycin, and imipenem against obligate anaerobic bacteria. J Antimicrob Chemother 1990; 25: 767–775.
32. Appelbaum PC, Spangler SK, Jacobs MR. Beta-lactamase production and susceptibilities to amoxicillin, amoxicillin-clavulanate, ticarcillin, ticarcillin-clavulanate, cefoxitin, imipenem, and metronidazole of 320 non-Bacteroides fragilis Bacteroides isolates and 129 fusobacteria from 28 U.S. centers. Antimicrob Agents Chemother 1990; 34: 1546–1550.
33. Moreno S, Garcia-Altazano J, Pinilla B, et al. Lemierre’s disease: postanginal bacteremia and pulmonary involvement caused by Fusobacterium necrophorum. Rev Infect Dis 1989; 11: 319–324.
34. Ahkee S, Srinatha L, Huang A, et al. Lemierre’s syndrome: postanginal sepsis due to anaerobic oropharyngeal infection. Ann Otol Rhinol Laryngol 1994; 103: 208–210.
35. Ma M, Jauch EC, Johnson MC. A case of Lemierre’s syndrome. Eur J Emerg Med 2003; 10: 139–142.
36. Leugers CM, Clover R. Lemierre syndrome: postanginal sepsis. J Am Board Fam Pract 1995; 8: 384–391.
37. Armstrong AW, Spooner K, Sanders JW. Lemierre’s syndrome. Curr Infect Dis Rep 2000; 2: 168–173.
38. Falagas M, Vardakas KZ, Athanasiou S. Intravenous heparin in combination with antibiotics for the treatment of deep vein septic thrombophlebitis: a systematic review. Eur J Pharmacol 2007; 557: 93–98.
39. Bach MC, Roediger JH, Rinder HM. Septic anaerobic jugular phlebitis with pulmonary embolism: problems in management. Rev Infect Dis 1988; 10: 424–427.
40. Goldhagen J, Alford BA, Prewitt LH, et al. Suppurative thrombophlebitis of the internal jugular vein: report of three cases and review of the pediatric literature. Pediatr Infect Dis J 1988; 7: 410–414.
41. Hoehn KS. Lemierre’s syndrome: the controversy of anticoagulation. Pediatrics 2005; 115: 1415–1416.
42. Mai C, Hunt D. Upper-extremity deep venous thrombosis: a review. Am J Med 2011; 124: 402–407.
43. Rathbun SW, Stoner JA, Whitsett TL. Treatment of upper-extremity deep vein thrombosis. J Thromb Haemost 2011; 9: 1924–1930.
44. Kearon C, Kahn SR, Agnelli G, et al. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest 2008; 133 (6 suppl): 454S–545S.
45. Hodgson R, Emiq M, Pisarello J. Hyperbaric oxygen (HBO2) in the treatment of Lemierre syndrome. Undersea Hyerb Med 2003; 30: 87–91.