Otogenic Lemierre syndrome: clinical diagnosis and urgent mastoidectomy

Problem: Lemierre syndrome is an infectious thrombophlebitis of the internal jugular vein commonly caused by Fusobacterium necrophorum. In young children, the diagnosis is often delayed due to lack of typical signs of mastoiditis. Cases: Two young girls presented to the emergency department with progressive fever, otalgia, otorrhea, and torticollis. Both were receiving antibiotics. Computerized tomography (CT) of the temporal bone showed opacified mastoid, with extensive thrombus of the internal jugular vein and sigmoid sinus. Case 1 underwent an urgent mastoidectomy with bilateral placement of ventilation tubes, and her antibiotic treatment was switched to ceftriaxone, metronidazole, and vancomycin. Case 2 was immediately started on triple intravenous antibiotic therapy after placement of ventilation tubes. A mastoidectomy was needed later due to deterioration of her clinical condition. Bacterial cultures were negative in both patients. Conclusion: Diagnosis of otogenic Lemierre syndrome should be based on severe ear infections complicated by thrombophlebitis on imaging.