As most readers know, I have studied pharyngitis for over 30 years.  Over the past 5 years I have had an epiphany.  After years of focusing only on adult strep pharyngitis, I now worry more about fuso pharyngitis.

Let us define some terms:

1.     Adult pharyngitis – in this discussion we will focus on15-30-year-old patients with acute pharyngitis

2.     Fusobacterium necrophorum is the predominant bacterial cause of Lemierre Syndrome.  The Lemierre Syndrome starts with acute pharyngitis that improves over 4-5 days.  Then the patients develop rigors, night sweats and high fevers.  Suppurative internal jugular thrombophlebitis develops and then the patient has septic emboli – most commonly to the lungs, but they can also go to the brain, joints or liver.

3.     We cannot easily diagnose fuso pharyngitis.  Because Fusobacterium necrophorum is a gram-negative anaerobe, the bacterium does not grow on routine throat cultures.

We have three lines of evidence for fuso pharyngitis.   First, we have both PCR and culture (special media) studies of pharyngitis patients.  Second, we have documented bacteremic fuso pharyngitis in six patients.  These reports include some clinical evidence.  Finally, we have throat cultures from patients with a syndrome of recurrent tonsillitis.  These patients responded to antibiotics with a cure of their syndrome.

In a recent simulation, I suggested that 1 in 400 adult fuso pharyngitis patients would develop Lemierre Syndrome.  Through a series of assumptions this translates to 1 in 70,000 adults (15-30) developing this syndrome each year.  While clearly a rare disease, this disease has devastating complications.

Since Lemierre Syndrome almost always follows pharyngitis in this age group, we have an opportunity to prevent a suppurative complication of pharyngitis that has an estimated death rate of 5% and a significant morbidity rate of almost 10%.  Moreover, even when patients have prompt diagnosis, they often have prolonged and complicated admissions and slow clinical recovery.

We believe that if we could both diagnose fuso pharyngitis and treat it appropriately, then we would likely prevent both Lemierre Syndrome and other suppurative complications (most often peritonsillar abscess).  Our problem in 2012 is that cannot routinely diagnose this infection.  Routine cultures do not work.  We have no tests (rapid tests or commercially available PCR) that will diagnose fuso pharyngitis.

Perhaps empiric treatment with appropriate antibiotics can markedly reduce the incidence of Lemierre Syndrome.  We have some indications that the prediction model for group A strep (1 point each for tonsillar exudates, tender anterior cervical adenopathy, fever history and a lack of cough) will also work for Fusobacterium pharyngitis.  In the review of bacteremic fuso pharyngitis, 5 of 6 patients had exudates, and all had fevers.  These reports did not comment on coughing or cervical adenopathy.  In Kristensen’s review of localized Fusobacterium infections, she reports positive cultures in patients with pharyngitis, fever and unilateral adenopathy.  That report does not mention cough or exudates.

The prediction model likely diagnoses bacterial pharyngitis, both strep pharyngitis (GAS as well as other Groups such as C and G) and fuso pharyngitis.  The signs and symptoms in the prediction model likely reflect a bacterial inflammatory response (exudates and anterior cervical adenopathy), a febrile response (fever history) and the lack of a viral response (lack of a cough).

We have a missing step at this time.  We must prospectively collect data on the signs and symptoms of fuso pharyngitis to test the hypothesis that I have proposed.  Currently we are trying to collect such data using a PCR research test.

I hope this short rant makes clear my thoughts as of today.  I would comments from both patients and physicians.

My strategy in 2012 for patients 15-30, if they have a prediction score of 3 or 4, I recommend treating with a penicillin or a cephalosporin.  In this age group we should never use macrolides or quinolones for pharyngitis, because Fusobacterium necrophorum is not sensitive to those antibiotics.