Lemierre Syndrome: From Scalp to Cerebrum
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Publication Date
4-29-2026
Keywords
oregon, ppmc, ppmc gme
Disciplines
Medical Education
Abstract
Background: Lemierre syndrome is a rare but severe infection, most commonly caused by Fusobacterium species originating from head and neck sources. Intracranial complications occur in only 11% of cases and are particularly uncommon in the absence of internal jugular vein thrombosis or endocarditis. Case Presentation: A 32-year-old previously healthy woman was admitted with sepsis due to Fusobacterium necrophorum bacteremia. Three weeks earlier, she had been hospitalized for sore throat and community-acquired pneumonia; blood and bronchoscopy cultures were negative, and she was discharged on amoxicillin-clavulanate. On readmission, blood cultures were positive for Fusobacterium necrophorum and evaluation revealed a right parietal scalp abscess, which was surgically drained. Transthoracic e chocardiography showed no valvular vegetations, and CT imaging revealed no thrombosis or thrombophlebitis of the head or neck. She was treated with ceftriaxone and metronidazole and discharged in stable condition on oral antimicrobials. Two days later, she re-presented with acute left-sided sensory changes and weakness. Neuroimaging demonstrated a right frontoparietal brain abscess and parietal meningitis with thrombosis of the right calvarial subarachnoid veins. She underwent craniectomy and surgical evacuation of the brain abscess, followed by four weeks of intravenous antibiotics. Despite aggressive management, she was left with partial left-sided hemiparesis and required inpatient rehabilitation for significant functional deficits. Discussion: Lemierre syndrome classically presents as oropharyngeal infection with subsequent septic thrombophlebitis. This case is notable for its atypical progression: likely unrecognized Fusobacterium pneumonia, followed by bacteremia, extracranial scalp abscess, and ultimately contiguous intracranial abscess with hemiparesis, despite timely source control and appropriate antibiotics. In the largest series of over 700 Lemierre syndrome cases, 17% developed early complications after diagnosis and treatment, with 3.8% developing septic intracranial lesions. In this patient, the brain abscess was contiguous with the scalp abscess, suggesting spread via emissary veins connecting scalp veins to the dural venous sinuses. Multiple imaging studies failed to demonstrate internal jugular vein thrombosis, but thrombosis of subarachnoid veins near the abscess was identified, supporting local contiguous spread. This case underscores the persistence and severity of Fusobacterium infections and highlights the risk of serious complications despite aggressive therapy. It emphasizes the need for vigilance, follow-up imaging, and consideration of prolonged therapy in Fusobacterium bacteremia. Conclusion: Clinicians should maintain a high index of suspicion for intracranial extension in patients with Fusobacterium bacteremia, even in the absence of classic findings such as endocarditis or internal jugular vein thrombosis. Early recognition, aggressive management, and appropriate antimicrobial duration are essential to mitigate neurologic morbidity.
Specialty/Research Institute
Graduate Medical Education
Specialty/Research Institute
Internal Medicine
