Anticoagulation therapy for Lemierre syndrome: a comprehensive review and individual participant data analysis

BACKGROUND: Lemierre's syndrome is a life-threatening infection characterized by septic thrombophlebitis of the internal jugular vein and septic embolism. Antimicrobial therapy is an established treatment for Lemierre's syndrome; however, its role in anticoagulation therapy remains unclear. OBJECTIVE: To evaluate the association between anticoagulation therapy initiated concurrently with antimicrobial therapy and the clinical outcomes in patients with Lemierre syndrome. METHODS: We comprehensively searched the PubMed, Embase, and Ichushi databases for case reports, case series, and cohort studies. Lemierre syndrome was defined as (1) a preceding oropharyngeal infection and (2) internal jugular vein thrombophlebitis or septic pulmonary emboli confirmed by imaging or pathology. We performed a case-control analysis and estimated odds ratios using multivariate logistic regression after adjusting for potential confounders. RESULTS: Of the 2051 screened records, internal jugular vein thrombus progressed in 15 patients (7.18% [15/209]) who received anticoagulation therapy and in 21 patients (18.8% [21/112]) who did not. The median age of the patients was 25 years (interquartile range, 18-45 years), and the baseline characteristics were generally balanced between the anticoagulated and non-anticoagulated patients. For the primary outcome of thrombus progression, anticoagulation therapy was associated with a significantly lower risk compared with no anticoagulation therapy (multiple imputation odds ratio 0.34, 95% CI 0.16-0.70). We observed no clear differences in the incidence of new septic pulmonary emboli (multiple imputation odds ratio 0.45, 95% CI 0.18-1.13) or major bleeding events (multiple imputation odds ratio 1.50, 95% CI 0.44-5.08). CONCLUSION: Our study suggests that although anticoagulation therapy is associated with a significantly reduced risk of IJV thrombus progression, it does not confer a clear benefit for other clinically important outcomes, such as new septic pulmonary emboli or mortality. Therefore, routine initiation of anticoagulation therapy may not be supported for Lemierre syndrome, particularly when the thrombus is limited to the internal jugular vein. Further well-designed observational studies are warranted. CLINICAL TRIAL NUMBER: Not applicable.