Ontario Girl Suffers Septic Shock After Third Molar Removal

A newspaper article¹ in the Orangeville Banner provided an account of a 16-year-old girl who experienced
serious complications after the removal of her wisdom teeth. Mercedes Moore of Grand Valley, Ontario, went
into septic shock after surgery in February 2009. The article outlines how an infection spread to her lungs
and brain, leading to her suffering a series of blood clots and strokes. She was ultimately placed into a medically
induced coma to allow treatment of the infection in her lungs and brain.

Mercedes spent over 10 weeks at McMaster Sick Children’s Hospital in Hamilton, Ontario, before being
transferred to Bloorview Kids Rehab centre in Toronto for another 5 months of rehabilitation.² She remains
partially paralyzed in her right arm and leg and will require further rehabilitation.

Commentary by Dr. George Sándor

The article in the Orangeville Banner describes a very sad and unfortunate case of an otherwise healthy teenager who
suffered postoperative complications associated with the removal of her third molar teeth due to an exceedingly rare
condition known as Lemierre syndrome. The JCDA readership is well acquainted with many unusual infectious complications
of third molar surgery, including Ludwig’s angina,¹ mediastinitis, life-threatening hemorrhag² and necrotizing
fasciitis.³

Lemierre syndrome can result from a recent oropharyngeal infection. Clinical or radiographic signs of the condition
include thrombosis of the internal jugular vein, distant infected emboli and the presence of anaerobic pathogens, usually
Fusobacterium necrophorum. It is the septic emboli resulting from the infected thrombophlebitis of the internal jugular
that causes complications of the central nervous system and pulmonary or other manifestations, including septic shock.
This condition was so rare that historically it was called the “forgotten disease,” but recent reports indicate that Lemierre
syndrome may be more common than we thought.⁴ Some authors attribute the apparent higher incidence to antibiotic
prescription patterns and antibiotic resistance.⁴

Because Lemierre syndrome is most commonly associated with oropharyngeal infection sometimes following tonsillectomy,
it is often described in the otolaryngology literature. While sepsis from a throat infection was first described
by Schottmuller in 1918,⁵ Andre Lemierre published a case series of 20 patients who had throat infections followed by
anaerobic septicemia.⁶ Eighteen patients in this series died. Lemierre syndrome has a high mortality rate, and for survivors,
the morbidity is severe. Successful management of such a complex and relatively unknown condition relies on a high
index of suspicion, awareness of the condition and soliciting the help of a multidisciplinary team.