Case Presentation: This is a 21 year old male with no significant past medical history presenting with shortness of breath and fever. Five days prior to presentation, he noted sore throat, fevers, and heart burn so he presented to an acute care clinic. He had a positive rapid strep screen, so he was given azithromycin due to a history of penicillin allergy. He continued having worsening dyspnea and then a cough productive of clear sputum. When presenting to our ER, he had fever to 40.1 C, tachycardia, tachypnea, and hypoxia requiring 3L oxygen. CT was concerning for pneumonia and a pulmonary abscess. He was given clindamycin until gram stains showed gram negative and gram positive rods. At this time the patient was converted to broad spectrum antibiotics but continued to have significant right sided chest pain, leukocytosis, fevers, and oxygen requirement. A CXR on day three of admission showed a large right sided pleural effusion. Blood cultures at this time came back positive for Fusobacterium necrophorum which raised concern for Lemierre’s syndrome. He was started on IV Clindamycin and a CT larynx (figure) and chest were obtained which showed empyema, pneumonia, and a clot in the left internal jugular vein. Surgery was consulted for decortication and he was eventually discharged on post-op day 5. On follow-up 2 weeks later, he was on clindamycin but feeling much better. Of note, he also had allergy testing that showed he did not have a true allergy to Penicillin.
Discussion: Lemierre’s Syndrome refers to the progression of a bacterial throat infection to thrombophlebitis of the internal jugular vein. This thrombophlebitis can have serious implications when it leads to bacteremia and septic emboli. Most commonly the lungs are a site of metastatic infection. Other possible metastatic infections include septic arthritis, osteomyelitis, pericarditis, hepatic abscesses, and meningitis. Lemierre’s Syndrome is most commonly caused by Fusobacterium, which are normal flora of the oral cavity and gastrointestinal tract. They are slow growing, anaerobic, gram-negative bacilli which are susceptible to Penicillin.
This constellation of symptoms occurs because a bacterial infection progresses to the formation of an abscess in the peri-tonsillar tissue. Inside the abscess, anaerobic bacteria can flourish. When this abscess ruptures, the bacteria can infect nearby structures including the internal jugular vein. In most cases, this process is interrupted early in the course with Penicillin for strep throat. With increased use of penicillin for bacterial throat infections since the 1960s, the number of reports of Lemierre’s syndrome has dropped significantly. In our case, the patient had a charted “unknown allergy to Penicillin,” so he received Azithroymycin for a perceived strep throat infection. Fusobacterium species is much more likely to be resistant to Azithromycin than Penicillin. He was tested and found not to have a true allergy to Penicillin making this hospitalization preventable.
Conclusions: Lemierre’s syndrome is a rare complication following an acute oropharyngeal infection with the common use of Penicillin to treat strep throat in modern medicine. Unfortunately, many patients get labeled with a Penicillin allergy at a young age and are therefore more susceptible to complications of not receiving the most appropriate treatment for an illness such as strep throat. Hospitalists should be more suspicious of this syndrome in patients with a listed penicillin allergy.
