Case Presentation:

A 24–year–old Caucasian male with no past medical history presented with 3–4 days of nausea/vomiting, weakness, sore throat, right lower quadrant pain, and subjective fever. The physical exam showed a fever of 101.8 with mild pharyngeal erythema with no exudates and right anterior cervical lymphadenopathy. WBC was 6,300 u/L with 51% neutrophils and 41% bands, hemoglobin 13.3g/dL and platelets 114,000 u/L. His creatinine was 1.7 mg/dL and LFTs were normal. The patient had a rapid strep, rapid flu, and monospot that were negative. He underwent an abdomen CT scan to evaluate him for appendicitis which was negative. Patchy nodular opacities were present in the lower lungs. Lumbar puncture and urinalysis were negative. The following morning the patient developed right neck swelling/tenderness and underwent a CT scan of his neck. The CT scan of the neck demonstrated soft tissue swelling of the pharyngeal tissue, small possible abscess of the palatine tonsil, and a thrombus in the internal jugular (IJ) vein. The patient was diagnosed with Lemierre’s syndrome and started on meropenem and vancomycin. CT scan of the chest showed multifocal airspace opacities suspicious for septic emboli. Blood cultures demonstrated fusobacterium necrophorum. The patient later developed difficulty swallowing with mild increased neck swelling and was transferred to a tertiary care center. The patient had extension of the IJ thrombus and was started on heparin/coumadin a few days later. He was discharged on a prolonged course of penicillin and flagyl.

Discussion:

Lemierre’s syndrome is often referred to as the “forgotten disease.” The disorder was described by Dr. Andre Lemierre in 1936 and has an incidence of between 0.6 and 2.3 per million people. The syndrome occurs with development of an oropharyngeal infection, disseminated abscesses and subsequent infectious thrombophlebitis with an IJ vein thrombus. The pathogen often associated with thissyndrome is fusobacterium necrophorum and can cause septic emboli to various organ systems.

Conclusions:

Lemierre’s syndrome often occurs in young healthy adults with nonspecific symptoms of sore throat, fever and neck swelling/tenderness. It usually begins with pharyngitis or tonsillitis that spreads to deep pharyngeal tissue and allows anaerobic organisms to spread which leads to IJ vein septic thrombophelibitis. As hospitalists, we must be vigilant of the rare complications of pharyngitis or tonsillitis. Even though, Lemierre’s syndrome is uncommon, it has a high mortality and morbidity if not recognized early.