Case Presentation: A 32-year-old man with alcohol use disorder complicated by delirium tremens, who initially presented with left ankle pain, was later found to have septic arthritis. He was admitted to the ICU for alcohol withdrawal, altered mental status (AMS), and sepsis in the setting of septic arthritis, with gram-positive cocci identified on ankle aspiration. Despite proper antibiotic therapy, his hospital course was complicated by waxing and waning mental status. Brain MRI revealed extensive cavernous sinus thrombosis extending into the internal jugular vein, initially suspected to be related to coagulopathy. Subsequently, the patient developed tender swelling of the left chest wall. CT chest revealed multiple large abscesses in the left lower neck, extending to the left clavicle and into the mediastinum, findings consistent with Lemierre syndrome (LS). The patient underwent incision and drainage of the left neck abscess, which grew gram-positive cocci, matching the culture from the ankle aspiration. He was successfully treated with antibiotics and surgical drainage.
Discussion: LS is a rare, but serious condition that presents with a combination of oropharyngeal infection, septic thrombophlebitis of the internal jugular vein, and distant septic emboli most commonly affecting the lungs. The typical presentation includes antecedent pharyngeal signs, sore throat, fever, and tonsillar involvement. Common complications include lung lesions secondary to septic emboli. In our case, the diagnosis of LS was not initially suspected because of its atypical presentation with AMS, septic shock, septic arthritis, coagulopathy, and alcohol withdrawal. However, LS was suspected when imaging revealed thrombosis in the internal jugular vein with multiple septic emboli and the patient later developed chest wall swelling. His clinical progression and radiographic findings further supported this diagnosis, highlighting the importance of timely and accurate imaging and microbiologic testing. This case emphasizes the fact that if sepsis does not improve despite appropriate antibiotic treatment, uncommon causes should not be excluded and in cases where a patient is unable to provide a clear history due to AMS as in our scenario, a detailed physical exam is crucial in pursuing a diagnosis especially considering a life-threatening condition like Lemierre’s Syndrome.
Conclusions: It is challenging to suspect LS, especially in complex presentations without the classic symptoms. Given the potential for life-threatening complications, clinicians should maintain a high level of suspicion for Lemierre’s syndrome, especially in patients with unusual presentations. This case underscores the importance of early diagnosis and treatment in managing this potentially deadly condition.