Don't Lament Lemierre!

No article here, but I wanted to reiterate an entity that is gaining more recognition: Lemierre syndrome.
WHEN  do I consider this lethal entity? Awareness of this dangerous disease occurs anytime someone starts with pharyngitis and returns 3-6 days later with markedly worse fever and neck pain. Once again, beware of the bounceback!!!!! 

WHAT is Lemierre syndrome? Lemierre is a syndrome of bacterial infection that starts in the throat, then progresses. The #1 pathogen is Fusobacterium necrophorum, but Staph and Strep are also in the mix. The start is with a sore throat, then fevers of 102-105F, 4-5 days later. Then, while the sore throat may lessen, new neck pain, chills, dysphagia, and dyspnea develops, along with malaise and night sweats. Basically, an abscess is forming a suppurative thrombophlebitis of the IJV. The final death knell is usually lung involvement with septic pulmonary emboli.
In summary, the 4 classic Lemierre criteria are:

• recent oropharyngeal infection
• clinical or radiographic evidence of IJV thrombosis
• isolation of anaerobic pathogens
• evidence of at least one septic focus, often the lungs (this means watch out for pleuritic chest pain!)

WHAT do I do in the Express Care with a patient whom I think has Lemierre? Run like hell! No, just kidding.  Lemierre victims emergently need a CT with contrast of the neck and chest to first check the internal jugular vein, and second, to check for pulmonary emboli. Obviously EMS may be needed depending on the patient's appearance and respiratory status.

In summary, most of us when confronted with a "bounceback" sore throat with worse fever and neck pain will think mono, or perhaps even PTA. However, this 3rd option should be kept in your diagnostic acumen!

Making Your Suturing a "Cut" Above

http://www.jfponline.com/home/article/a-guide-to-better-wound-closures/da908f34dd436bab74e1fe982565ced9.html

The above link (if it goes down just search the article on www.jfponline.com) has some nice, classic tips on proper sewing for not just good, but great, outcomes. A few highlights, but again the article is encouraged:

• NEVER underestimate the importance of a well documented flushing of the wound. Again, avoid alcohol or anything that could harm the new, regenerating tissue. A solid rule is the old maxim, "don't put anything in a wound to clean it that you would not put in your eye!"
• Note the table on suggested suture removal times. In the real world, I have long railed against the "usual 7 days" for MOST wounds (ie- those from the neck down excluding the fast healing well vascularized face and scalp). I totally concur with the table in that the majority of our express care lacs need 10-14 days.
• The # 1 tip to go from good to great in sewing is this: EVERT the edges so dermis matches dermis. Many subtle tricks, ranging from deep, tension relieving mattress sutures to undermining the wound edges exist. The key is to aggressively utilize these tips consistently!