T h e n e w e ngl a nd j o u r na l o f m e dic i n e

n engl j med 364;24 nejm.org june 16, 20112366

exchange and bortezomib is remarkably effective in reversing acute renal failure presumed second-ary to cast nephropathy in patients with myeloma. Further study of this strategy and of plasma ex-change in the era of a new generation of therapeu-tic options is warranted.Brian L. Burnette, M.D. Nelson Leung, M.D. S. Vincent Rajkumar, M.D.Mayo Clinic Rochester, MN rajkumar.vincent@mayo.edu

Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.

1. Leung N, Gertz MA, Zeldenrust SR, et al. Improvement of cast nephropathy with plasma exchange depends on the diagno-sis and on reduction of serum free light chains. Kidney Int 2008; 73:1282-8.2. Clark WF, Stewart AK, Rock GA, et al. Plasma exchange when myeloma presents as acute renal failure: a randomized, controlled trial. Ann Intern Med 2005;143:777-84. [Erratum, Ann Intern Med 2007;146:471.]3. Johnson WJ, Kyle RA, Pineda AA, O’Brien PC, Holley KE. Treatment of renal failure associated with multiple myeloma: plasmapheresis, hemodialysis, and chemotherapy. Arch Intern Med 1990;150:863-9.

Streptococcal Pharyngitis

To the Editor: The article by Wessels (Feb. 17 issue)1 focuses on group A β-hemolytic strepto-coccal infection, which has been considered the only commonly occurring form of acute pharyngi-tis for which antibiotic therapy is indicated. How-ever, cases of bacteremic infection caused by Fuso-bacterium necrophorum have recently been reported in young patients,2 and some complications have also been reported among patients with acute pharyngitis caused by groups of streptococci oth-er than group A, such as virulent strains of strep-tococci C and G,3 thereby extending the cases of pharyngitis that require antibiotic therapy. The role of antibiotic therapy in these cases is not dis-cussed, but the number of cases caused by these germs is not negligible; in our area, group C streptococcal infection accounts for more than 10% of cases of streptococcal pharyngitis.4

Carl Llor, M.D., Ph.D.University Rovira i Virgili Tarragona, Spain carles.llor@urv.cat

No potential conflict of interest relevant to this letter was reported.

1. Wessels MR. Streptococcal pharyngitis. N Engl J Med 2011; 364:648-55.2. Centor RM. Expand the pharyngitis paradigm for adoles-cents and young adults. Ann Intern Med 2009;151:812-5.3. Hanna BC, McMullan R, Gallgaher G, Hedderwick S. The epidemiology of peritonsillar abscess disease in Northern Ire-land. J Infect 2006;52:247-53.4. Llor C, Calviño O, Hernández S, et al. Repetition of the rapid antigen test in initially negative supposed streptococcal pharyn-gitis is not necessary in adults. Int J Clin Pract 2009;63:1340-4.

The author replies: Llor raises a question about whether antibiotic treatment is indicated

for pharyngitis due to streptococcus group C or G or fusobacterium species. A discussion of the evaluation and treatment of other causes of pharyngitis was beyond the scope of the article. Although some studies suggest that group C streptococci and F. necrophorum may cause phar-yngitis, the implications of a positive throat cul-ture are unclear, since these organisms can also be recovered from asymptomatic individuals, and it is unknown whether treatment prevents complications.1,2 However, high fever and sys-temic toxicity associated with unilateral neck pain and swelling should raise suspicion not only for peritonsillar abscess, but also for septic jugular-vein thrombophlebitis (Lemierre’s syn-drome), the latter usually being due to F. necropho-rum infection. As Llor points out, this syndrome is seen most often in adolescents and young adults.1,3 Diagnosis is established by a positive blood culture and visualization of a jugular-vein thrombus.

Michael R. Wessels, M.D.Children’s Hospital Boston Boston, MA michael.wessels@childrens.harvard.edu

Since publication of his article, the author reports no further potential conflict of interest.

1. Centor RM. Expand the pharyngitis paradigm for adoles-cents and young adults. Ann Intern Med 2009;151:812-5.2. Turner JC, Hayden FG, Lobo MC, Ramirez CE, Murren D. Epidemiologic evidence for Lancefield group C beta-hemolytic streptococci as a cause of exudative pharyngitis in college stu-dents. J Clin Microbiol 1997;35:1-4.3. Chirinos JA, Lichtstein DM, Garcia J, Tamariz LJ. The evolu-tion of Lemierre syndrome: report of 2 cases and review of the literature. Medicine (Baltimore) 2002;81:458-65.

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