Published online May 2, 2005
PEDIATRICS Vol. 115 No. 5 May 2005, pp. 1415-1416 (doi:10.1542/peds.2005-0138)

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COMMENTARY

Lemierre’s Syndrome: The Controversy of Anticoagulation

K. Sarah Hoehn, MD, Mbe

Department of Anesthesiology and Critical Care Medicine
Children’s Hospital of Philadelphia
Philadelphia, PA 19104

Abbreviations: LS, Lemierre’s syndrome

In this issue of Pediatrics, Schmid et al¹ present an important case of respiratory failure and hypercoagulability in a toddler with Lemierre’s syndrome (LS). The first significant finding is the young age of the patient. Given the increasing prevalence of LS, one needs to have a high index of suspicion in all pediatric age groups, not just adolescents.^2,3 The second important finding includes the potential implications of screening for and finding underlying thrombophilia. In addition, the possibility of underlying thrombophilia predisposing one to LS is a novel concept.

Internal jugular venous thrombosis is the hallmark of LS, but the role of anticoagulation is controversial.^4,5 One potential indication for anticoagulation is a cerebral infarct or sinus venous thrombosis.⁶ In 1 case of cavernous sinus thrombosis in the setting of LS, the patient was treated with aspirin.⁶ Another case report documented the use of both enoxaparin and warfarin.⁷ Advocates of anticoagulation discuss the potential earlier resolution of thrombophlebitis and bacteremia.² Some advocate using anticoagulation only if there is evidence of retrograde progression to the cavernous sinus.³ One case series reported using anticoagulation in 3 of the 5 patients.² None of these reports addressed the potential of an underlying thrombophilia.

The challenge of managing LS in the intensive care unit setting is twofold: having a high index of suspicion to diagnose LS and managing anticoagulation in the setting of multiorgan system failure, including pulmonary infarcts from septic emboli. Our institution had a patient with LS who had a pulmonary hemorrhage temporally related to the initiation of anticoagulation with lovenox. Schmid et al report in their case study initiating anticoagulation with lovenox, with resolution of the thrombus. The role of anticoagulation in the setting of LS with multiorgan system failure should be explored systematically.

In summary, this important case report stimulates us to consider the diagnosis of LS in younger patients, in addition to consideration of an evaluation for underlying thrombophilia and anticoagulation. Because there is continued controversy over the role of anticoagulation, perhaps the existence of underlying thrombophilia should guide our management.

	FOOTNOTES

 
Accepted Jan 20, 2005.

Address correspondence to K. Sarah Hoehn, MD, Mbe, Department of Anesthesiology and Critical Care Medicine, 9th Floor, Main Building, Children’s Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104. E-mail: hoehn{at}email.chop.edu

No conflict of interest declared.

	REFERENCES

TOP REFERENCES

 

1. Schmid T, Miskin H, Schlesinger Y, Argaman Z, Kleid D. Respiratory failure and hypercoagulability in a toddler with Lemierre’s syndrome. Pediatrics. 2005;115 (5). Available at: www.pediatrics.org/cgi/content/full/115/5/e620
2. Ramirez S, Hild TG, Rudolph CN, et al. Increased diagnosis of Lemierre syndrome and other Fusobacterium necrophorum infections at a Children’s Hospital. Pediatrics. 2003;112 (5). Available at: www.pediatrics.org/cgi/content/full/112/5/e380
3. Riordan T, Wilson M. Lemierre’s syndrome: more than a historical curiosa. Postgrad Med J. 2004;80 :328 –334[Abstract/Free Full Text]
4. Hoehn S, Dominguez TE. Lemierre’s syndrome: an unusual cause of sepsis and abdominal pain. Crit Care Med. 1644;30 :1644 –1647
5. Chirinos JA, Lichtstein DM, Garcia J, Tamariz LJ. The evolution of Lemierre syndrome: report of 2 cases and review of the literature. Medicine (Baltimore). 2002;81 :458 –465[CrossRef][Medline]
6. Bentham JR, Pollard AJ, Milford CA, Anslow P, Pike MG. Cerebral infarct and meningitis secondary to Lemierre’s syndrome. Pediatr Neurol. 2004;30 :281 –283[CrossRef][Web of Science][Medline]
7. Bekelman JE, Francis JS, Berliner AR, DeRuiter CJ, Brown CD. Lemierre’s variant. Lancet Infect Dis. 2004;4 :518[Medline]

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PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Web of Science (6) Citing Articles via Google Scholar Google Scholar Articles by Hoehn, K. S. Search for Related Content PubMed PubMed Citation Articles by Hoehn, K. S. Related Collections Blood Social Bookmarking                         What's this?