January 21, 2018

Lemierre and Schottmüller

In reference to the recent case vignette, the eponymous Dr André Alfred Lemierre – Professor of Bacteriology at the Claude Bernard Hospital –  described the syndrome bearing his name in several papers, the most detailed being a report to the Lancet that was published on 28th March 1936.

Lemierre

Screen capture of the original Lancet article by Lemierre in 1936.

However, Dr Lemierre claimed that he was not the first to describe this syndrome of anaerobic microbes – primarily Fusobacterium necrophorum (the old name being Bacillus funduliformis among others) – causing septic thrombophlebitis of the internal jugular vein, but attributed it to German microbiologist Hugo Schottmüller who described “post-anginal septicaemia” in 1918 (“anginal” in this case relates to a pharyngeal or tonsillar abscess). I am not able to find the 1918 article (others – including researchers from Princess Alexandra Hospital – have contacted the journal editor, who had informed them that there was only an announcement of the discovery in the post-WWI publication). But there was a more substantial description in 1922 by Dr Schottmüller in the same journal (behind a paywall).

Schottmuller-1

Screen capture of the 1922 article by Dr Hugo Schottmuller describing oral diseases with distant manifestations.

However, Dr Lemierre was not strictly correct about who had first described the clinical syndrome which bears his name. This very first report is now believed to have been made by Dr Paul Courmont and Dr André Cade, both professors of pathology and bacteriology (and hygiene) in Lyon in 1900, describing human necrobacillosis (“Sur une septico-pyohemie de l’homme stimulant la peste et causee par un strepto-bacille anaerobie”. Archives de Medecine Experimentale et d’Anatomi Pathologique. 1900). I was also not able to find this article online.

So actually, Dr André Lemierre was neither the first to provide detailed reports about “postanginal internal jugular vein thrombophlebitis”, nor was he the first to describe the most common causative organism Fusobacterium necrophorum. Such are the vagaries of fame and fortune!

Nonetheless, he was the first to provide a concise and clear description of the entity, and his 1936 Lancet article was a model of clinical and bacteriological clarity on the syndrome that now bears his name (it is unfortunately behind an Elsevier paywall). I particularly like and had cause to ruefully reflect on one of the summary paragraphs: “To anyone instructed as to the nature of these septicemias it becomes relatively easy to make a diagnosis on the simple clinical findings. The appearance and repetition several days after the onset of a sore throat (and particularly of a tonsillar abscess) of severe pyrexial attacks with an initial rigor or still more certainly the occurrence of pulmonary infarcts and arthritic manifestations, constitute a syndrome so characteristic that mistake is almost impossible”.

For more on the principal organism that causes septic thrombophlebitis of the internal jugular vein – Fusobacterium necrophorum – there is an excellent review article in Clinical Microbiology Reviews in 2007.

While Lemierre’s syndrome is rare currently, it appeared to occur fairly commonly in the pre-antibiotic era. Dr Lemierre described how German doctors would – based on the clinical diagnosis alone and prior to the results of bacterial cultures – ligate the internal jugular vein on the side of the affected tonsil in an attempt to reduce the mortality from the infection. Certainly not the practice today!

How about Dr Schottmüller? He is more renowned today for his description of sepsis in 1914, which still stands the test of modern times: “Sepsis is present if a focus has developed from which pathogenic bacteria, constantly or periodically, invade the blood stream in such a way that this causes subjective and objective symptoms.” He also apparently stated: “A therapy should not be directed against bacteria in the blood but against the released bacterial toxins…”.

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Clinical microbiology, Infectious diseases

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