Lemierre Syndrome: Clinical Update and Protocol for a Systematic Review and Individual Patient Data Meta-analysis.

Lemierre syndrome usually affects otherwise healthy adolescents or young adults and occurs at an overall rate of 1 to 10 cases per million person-years with an estimated fatality rate of 4 to 9%. Diagnostic criteria remain debated and include acute neck/head bacterial infection (often tonsillitis caused by anaerobes at high potential for sepsis and vascular invasion, notably Fusobacterium necrophorum) complicated by local vein thrombosis, usually involving the internal jugular vein, and systemic septic embolism. Medical treatment is based on antibiotic therapy with anaerobic coverage, anticoagulant drugs and supportive care in case of sepsis. Surgical procedures can be required, including drainage of the abscesses, tissue debridement and jugular vein ligation. Evidence for clinical management is extremely poor in the absence of any adequately sized study with clinical outcomes. In this article, we illustrate two cases of Lemierre syndrome not caused by Fusobacterium necrophorum and provide a clinically oriented discussion on the main issues on epidemiology, pathophysiology and management strategies of this disorder. Finally, we summarize the study protocol of a proposed systematic review and individual patient data meta-analysis of the literature. Our ongoing work aims to investigate the risk of new thromboembolic events, major bleeding or death in patients diagnosed with Lemierre syndrome, and to better elucidate the role of anticoagulant therapy in this setting. This effort represents the starting point for an evidence-based treatment of Lemierre syndrome built on multinational interdisciplinary collaborative studies.

Human papilloma virus-associated squamous cell carcinoma of the larynx in an 18-year-old woman.

BACKGROUND: Human papilloma virus (HPV)-associated malignancies are considered to be sexually transmitted diseases. METHODS: We report a HPV-positive larynx cancer in an 18-year-old female clarinet player, despite vaccination with the quadrivalent HPV-6-11-16-18-vaccine Gardasil (Merck Sharp & Dohme Corp., West Point, Pennsylvania). The patient showed no evidence of genito-oral infection but showed some evidence for oral-oral HPV transmission through the sharing of saliva-infested clarinet mouthpieces. A right vocal cord lesion of benign appearance was removed via free margin resection. RESULTS: Histopathology revealed a microinvasive squamous cell carcinoma inside a zone of high-grade dysplasia that was positive for HPV-45. No tumor recurrence was observed during a 4-year follow-up evaluation. CONCLUSION: Benign lesion appearance and quadrivalent HPV vaccine status do not exclude HPV-associated malignancies. In our patient, the Gardasil vaccine did not provide crossover protection against HPV 45 infection. HPV-associated disease may not necessarily be transmitted via sexual practice patterns alone.

Septic thrombosis of the internal jugular vein: Lemierre's syndrome revisited.

OBJECTIVES/HYPOTHESIS: Study of the clinical evolution of a primary ear, nose, and throat infection complicated by septic thrombophlebitis of the internal jugular vein. STUDY DESIGN: Retrospective case-control study. PATIENTS AND METHODS: From 1998 to 2010, 23 patients at our institution were diagnosed with a septic thrombosis of the internal jugular vein. Diagnostics included microbiologic analysis and imaging such as computed tomography, magnetic resonance imaging, and ultrasound. Therapy included broad-spectrum antibiotics, surgery of the primary infectious lesion, and postoperative anticoagulation. The patients were retrospectively analyzed. RESULTS: The primary infection sites were found in the middle ear (11), oropharynx (8), sinus (3), and oral cavity (1). Fourteen patients needed intensive care unit treatment for a mean duration of 6 days. Seven patients were intubated, and two developed severe acute respiratory distress syndrome. An oropharynx primary infection site was most prone to a prolonged clinical evolution. Anticoagulation therapy was given in 90% of patients. All 23 patients survived the disseminated infection without consecutive systemic morbidity. CONCLUSION: In the pre-antibiotic time, septic internal jugular vein thrombophlebitis was a highly fatal condition with a mortality rate of 90%. Modern imaging techniques allow early and often incidental diagnosis of this clinically hidden complication. Anticoagulation, intensive antibiotic therapy assisted by surgery of the primary infection site, and intensive supportive care can reach remission rates of 100%.

Extended frequency range hearing thresholds and otoacoustic emissions in acute acoustic trauma.

OBJECTIVE: We sought to evaluate the relative value of pure tone audiometry (PTA), extended high-frequency audiometry (EFA) and transiently evoked otoacoustic emissions (OAE) and distortion products when monitoring acute acoustic trauma (AAT). STUDY DESIGN: Controlled prospective clinical study. SETTING: Tertiary referral center. PATIENTS: Seventy one active duty soldiers in the same age with normal hearing INTERVENTIONS: Forty one soldiers suffered assault-rifle-induced acute acoustic traumas with hearing loss and tinnitus. Thirty soldiers served as a control group. MAIN OUTCOME MEASURES: Pure tone threshold changes detected by PTA and EFA, amplitude and reproducibility changes in transiently evoked OAE, distortion products, and tinnitus analysis based on a visual analog scale. RESULTS: Assault rifle-induced AAT caused unilateral temporary threshold shifts (TTS) in PTA and bilateral TTS in EFA. Two frequency regions with the largest threshold shifts were identified: one between 3 and 6 kHz and another between 11 and 14 kHz. The reproducibility of transiently evoked OAEs revealed changes related to the acoustic trauma in the 3- to 5-kHz frequency window. The amplitudes of the low stimulation level distortion products at 6 kHz were correlated with the audiometric AAT-induced TTS. CONCLUSION: Acute acoustic trauma-induced audiometric TTS are predominantly confined to 2 specific frequency regions. PTA and EFA are both necessary to identify the full extent of acute acoustic trauma. PTA and EFA revealed that the TTSs were correlated to with distortion product OAE amplitude shifts at 6 kHz and changes in the reproducibility of transiently evoked OAE in the 3- to 5-kHz frequency window. PTA remains the most important measurement to monitor AAT. It may be useful to complement it with EFA, focusing on the 11 to 14 kHz frequency range. If used, OAE should be analyzed in the frequency range of 3 to 6 kHz.