Case Presentation:

We report a previously healthy 18–year–old female who presented to an urgent care clinic with low–grade fever and sore throat, she was given a 5–day course of Azithromycin for pharyngitis. Three days into her antibiotic course she experienced worsening throat and neck pain with a low–grade fever, she was instructed to continue her Azithromycin course. She then rapidly decompensate with hypoxic respiratory failure and DIC. CT head and neck showed a 1.2 × 1.0 cm left paratonsillar phlegmon and non–visualized left internal jugular vein (IJV) suggestive of thrombosis confirmed on ultrasound. Multifocal bilateral infiltrates suggestive of multiple septic pulmonary emboli were found on CT chest. Blood cultures grew group C beta hemolytic streptococci. Laryngoscopy showed left lateral pharyngeal wall erythema and mild swelling in the left vallecula. We elected to treat conservatively. After much deliberation, anticoagulation was started for her IJV thrombosis. IV Ampicillin–Sulbactam was started but she developed rash and fever so regimen was changed to oral Metronidazole and IV Vancomycin. She was discharged home with 4 weeks of antibiotic therapy. On follow up she was doing well and reimaging showed that her paratonsillar infection had improved, but left IJV thrombosis remained. She will continue warfarin therapy for duration of at least 3 months, although possibly longer depending on future serial imaging.

Discussion:

Complicated courses of pharyngitis are few; however, we report a potentially fatal associated syndrome that is making a resurgence of incidence in current practice. Healthcare providers need be cautious to prevent and recognize early cases of this hazardous complication on the rise; Lemierre’s Syndrome. Characterized by secondary suppurative thrombophlebitis of the neck veins following oropharyngeal infection, Lemierre’s syndrome frequently results in metastatic infections and fulminant sepsis with significant associated mortality. It has been theorized that antibiotic resistance, less liberal antibiotic prescription use, or lack of early recognition of bacterial infection by mid level practitioners may account for a rise in incidence of Lemierre’s Syndrome. The majority of cases occur in patients aged 16––25 and Fusobacterium necrophorum is the classic isolated organism, however other oropharyngeal pathogens have been described. The mainstay in treatment is IV antibiotic therapy directed against anaerobes and surgical intervention is required in certain cases. Septic thrombophlebitis typically occurs 4–8 days following primary infection, septic embolisms with subsequent metastatic abscesses are common. Anticoagulation therapy remains controversial, risk of thrombus propagation and embolism should be weighted against harm of potential hemorrhagic conversion of septic infarcts.

Conclusions:

Healthcare providers need be cautious to prevent and recognize early cases of this hazardous complication on the rise; Lemierre’s Syndrome.