Case Presentation: A 44-year-old female with no significant past medical history, initially came to the E.R. with fever, chills, sore throat, and a painfully swollen neck for the past 5 days. The sore throat was 10/10 in intensity. She reported dysphagia, and revealed that she failed outpatient antibiotics recently prescribed by her PCP for the same symptoms. CT of the neck with contrast showed fullness in the pharyngeal mucosal space and right tonsil, along with adenitis in the submandibular glands, and a possible peritonsillar abscess. Patient was found to be in severe sepsis on admission, and was started on clindamycin and azithromycin, secondary to a penicillin allergy, for bacterial pharyngitis. Solumedrol was given for significant throat inflammation. By this time her EBV, Influenza, Mono, and Strep test returned negative, but blood cultures returned positive for Fusobacterium necrophorum, and a delayed diagnosis of Lemierre’s was made. At this time, an U/S Doppler of the IJ was ordered, and ruled out an IJ thrombus. ID was consulted on the case, and she was discharged with oral cefdinir after her symptoms improved.
Discussion: This is a classic example of anchoring bias. The initial presentation may have seemed as if our young patient had an acute pharyngitis, when she presented with an inability to eat, and persistence of symptoms. Further differentials should have been sought. Lemierre’s can be a diagnostic challenge for most physicians. This case serves to raise awareness of this rare condition, and highlights the need for additional investigation when suspicion is high to rule out fatal complications of septic thrombophlebitis. Early diagnosis and prolonged treatment with antibiotics is curative and may be life-saving.
Conclusions: Even though a case of Lemierre’s is a rare occurrence in a case of pharyngitis, a high degree of clinical suspicion should be entertained for Lemierre’s when a young person comes in to the ED, even if initial blood work and imaging are normal, as there are fatal complications to this syndrome if missed.