The

n e w e ng l a n d j o u r na l

exchange and bortezomib is remarkably effective

in reversing acute renal failure presumed secondary to cast nephropathy in patients with myeloma.
Further study of this strategy and of plasma exchange in the era of a new generation of therapeutic 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

of

m e dic i n e

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 diagnosis 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, OBrien 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 -hemolytic streptococcal infection, which has been considered the
only commonly occurring form of acute pharyngitis for which antibiotic therapy is indicated. However, cases of bacteremic infection caused by Fusobacterium 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 other than group A, such as virulent strains of streptococci C and G,3 thereby extending the cases of
pharyngitis that require antibiotic therapy. The
role of antibiotic therapy in these cases is not discussed, 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 Ireland. J Infect 2006;52:247-53.

4. Llor C, Calvio O, Hernndez S, et al. Repetition of the rapid
antigen test in initially negative supposed streptococcal pharyngitis 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

2366

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 pharyngitis, the implications of a positive throat culture 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 systemic toxicity associated with unilateral neck
pain and swelling should raise suspicion not
only for peritonsillar abscess, but also for septic
jugular-vein thrombophlebitis (Lemierres syndrome), the latter usually being due to F. necrophorum 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.
Childrens 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 students. J Clin Microbiol 1997;35:1-4.
3. Chirinos JA, Lichtstein DM, Garcia J, Tamariz LJ. The evolution of Lemierre syndrome: report of 2 cases and review of the
literature. Medicine (Baltimore) 2002;81:458-65.

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