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Lemierres Syndrome - Terry Riordan PowerPoint Document

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Lemierres Syndrome - Terry Riordan PowerPoint Document

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    1. 1

    2. 2 F necrophorum and Lemierre’s syndrome Taxonomy Clinical picture of Lemierre’s syndrome Epidemiology Pathogenesis & host factors Diagnosis & Therapy F necrophorum in the throat

    3. 3

    4. 4 Fusobacterium necrophorum Taxonomy versus reality

    5. 5 Boudins

    6. 6 Bacillus funduliformis (Jean Hallé)

    7. 7

    8. 8

    9. 9 F necrophorum subsp funduliforme Clinical presentation

    10. 10 Clinical Case 16 year old girl previously fit Fever 39.5C & Severe lower abdo pain Preceding severe sore throat Chest X ray NAD, Abdo USS NAD Rx Imipenem & clindamycin

    11. 11 Next Day Pleuritic chest pain, SOB Massive pleural effusions foul smelling fluid, GNRs seen Underlying lung lesions appeared overnight GNRs growing in BCs Diagnosis suggested by Medical registrar!

    12. 12 Distribution of extrapulmonary lesions in 59/222 cases of Lemierre’s syndrome

    13. 13 Necrobacillosis, Postanginal sepsis & Lemierre’s syndrome

    14. 14 Lemierre’s syndrome criteria Anginal illness or compatible clinical findings & Metastatic lesions in lungs or remote site & Isolation of Fusobacterium sp from blood cultures or a normally sterile site. or Evidence of IJV thrombophlebitis

    16. 16 F necrophorum infection from throat & ear

    17. 17 Lemierre’s syndrome epidemiology Incidence 1/million popn/year Age 16-30 median 19 Sex M:F 2:1 Almost invariably previously fit

    18. 18 Diagnosis of Lemierre’s Classical spot clinical diagnosis Imaging IJV thrombosis Septic pulmonary emboli Culture Blood Pus from empyema, liver, joint etc

    19. 19

    20. 20 Identification of F necrophorum Gram stain morphology Yellow haemolytic colonies, cabbage smell Greenish yellow under UV Spot indole pos (p-dimethylcinnamaldehyde) Lipase positive Commercial kits – inadequately assessed

    21. 21 Therapy Antibiotics Do not use erythromycin Clindamycin chloramphenicol penicillin poor Metronidazole best but no rigorous data Surgical drainage Empyema Neck abscess Bone, joint Anticoagulants Adjunctive therapy

    22. 22 Endogenous infection with non-sporing anaerobes Massive populations of anaerobic organisms in normal flora of Oral cavity Gut Female genital tract Infection arises when breach of mucosal integrity occurs

    23. 23 F necrophorum as normal flora? Jean Hallé André Lemierre Gorbach & Bartlett etc etc etc But…… No published study has cultured F nec from oropharynx of healthy subjects Not found in studies of excised tonsils Most molecular studies found no evidence 1 PCR study 20% carriage in healthy student nurses and soldiers Jensen 2007 Clin Micro & Inf Dis

    24. 24 Events leading to Lemierre’s Acquisition of F necrophorum Predisposing viral infection Mucosal damage Thrombophilia Single nucleotide polymorphisms predisposing to severe sepsis

    25. 25 Events leading to Lemierre’s 1: Acquisition of F necrophorum

    26. 26 Events leading to Lemierre’s 2: F necrophorum & EBV Both F nec & EBV are associated with quinsy 10% of Lemierre’s cases have serological evidence of recent EBV Involvement of anaerobes in anginose IM

    27. 27 Anginose IM & anaerobes Increased recovery of anaerobes from tonsils during IM including Fuso sp & Prevotella sp Several studies showed more rapid clinical improvement in patients treated with metronidazole

    28. 28 F necrophorum & EBV Possible pathogenic mechanisms Ig Production T cells Ulceration

    29. 29 Events leading to Lemierre’s 4: Mucosal damage Viral infection Deep throat cellulitis Ball point pen injury Post tonsillectomy

    30. 30 Events leading to Lemierre’s 5: Thrombophilia Numerous case reports of thrombophilia in patients with Lemierre’s syndrome. No systematic study undertaken Seems very plausible as a contributory factor

    31. 31 Changing epidemiology of Lemierre’s syndrome 1900-1940s Many reports of post anginal sepsis Collections of cases, Lemierre, Alston etc 1940s-1970s Reduction of cases of post anginal sepsis in antibiotic era Disappearance of anaerobic bacteraemia 2ary to tonsillitis Loss of clinical awareness 1980s- 2007 Re-emergence of awareness ? Changing incidence

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    33. 33 Possible explanations Awareness and publication bias Tonsillectomy rates Human behaviour Reduced use of antibiotics for sore throat

    34. 34

    35. 35 Antibiotics for sore throats 50% of cases used macrolide Real shift in prescribing rates - 50% reduction Some guidelines are based on GAS detection Timing of changes and rising incidence

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    38. 38 F necrophorum and sore throat Batty & Wren J Infection 2005 41yr woman Recurrent tonsillitis for 24 years beginning after Infectious Mononucleosis Repeated Rx for GAS without benefit Penicillin allergic T/S ? GAS & F necrophorum Rx with metronidazole ? rapid, sustained clinical response and disappearance of nodes

    39. 39 F necrophorum and sore throat Aliyu et al J Med Micro 2004 100 clinical throat swabs from Primary care and 100 swabs from healthy adults Tested by PCR for F nec DNA 10/100 cases +ve 0/100 controls +ve 4/10 had recurrent or persistent illness

    40. 40 F necrophorum and sore throat Batty BJ Biomed Sci 2005 248 unselected throat swabs F nec isolates were mainly from teenagers and young adults Highest isolation rate was in patients with “persistent sore throat syndrome”

    41. 41 F necrophorum and sore throat Jensen et al Clin Microbiol & Infection 2007 PCR detection of F nec 61 cases with non GAS tonsillitis vs 92 healthy controls F nec detected in 48% and 21% respectively Now routinely culture for F nec and detect in 15% of swabs

    42. 42 Age, EBV & F necrophorum

    43. 43 Tonsillectomy & sore throat

    44. 44 F necrophorum and sore throat No controlled trials of antibiotic therapy Need to expand the Jensen study and look at duration of carriage, carriage in children etc Need more data before writing it in the text books

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    46. 46 F necrophorum subsp funduliforme The real story? Not part of the normal flora Exposure occurs in late teens & early 20s Probably kissing or sexual Common cause of tonsillitis esp recurrent Progression to Lemierre’s depends on Mucosal trauma EBV or other viral infection Genetic factors such as thrombophilia

    47. 47 Laboratory role Should we look for F. nec in throat swabs? Know the Gram stain morphology in BCs Fully identify anaerobes from BCs incl ref lab referral Beware of “mixed anaerobes sensitive to metronidazole”.

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