Case Presentation: Lemierre’s disease is a rare and deadly infection caused by the Fusobacterium species which results in bacterial pharyngitis that spreads through pharynx soft tissues into the carotid arteries, resulting in widespread bacteremia and thrombosis. Outcomes are reliant on early diagnosis and initiation of treatment, with mortality rates as high as 20%. The rarity of its occurrence and generalizable early symptoms makes Lemierre’s a challenging diagnosis. A 20-year-old female presented to a primary care clinic after one day of severe pharyngeal pain. On presentation, patient was mildly febrile and had difficulty swallowing and speaking due to pain. Strep test was negative, she was prescribed azithromycin (Z-Pak), and sent home. Patient completed antibiotic course and experienced symptom resolution, however symptoms returned within 24 hours of medication cessation. For several days, she experienced cyclic high fevers, extreme throat pain preventing oral intake, and dizziness. Three weeks after initial presentation and one week after antibiotic completion, she presented again to her primary care office. Patient was afebrile, repeat strep swab was negative, and she was again sent home. Three days later she returned, febrile and dehydrated, and was admitted for further workup. Upon admission she was found to have thrombocytopenia secondary to disseminated intravascular coagulation and sepsis. After several days of deteriorating symptoms, several negative blood cultures, and increasing fever, blood cultures taken during a high fever were positive for Fusobacterium nucleatum, prompting Lemierre’s workup. Patient was started on IV Unasyn. CT angiogram revealed bilateral lung patchy pulmonary infiltrates, diffuse multifocal consolidative densities, as well as mediastinal and bilateral hilar lymphadenopathy consistent with bilateral septic emboli. TTE and TEE were obtained, both indeterminate for cardiac complications. A final decision was made to treat with only oral antibiotics for 6 weeks with close follow up, serial CT scans, and repeat labs in clinic. During follow-up, patient was further diagnosed with pneumonia following her pulmonary injuries, and was having extreme difficulty walking to and from her dorm room due to SOB. As she was already on oral antibiotics and repeat CT showed improvement in pulmonary injury, she was told to limit activity for several weeks and return to clinic. Patient experienced improvement in breathing over the following appointments, and successfully completed treatment in March of 2020.
Discussion: Traditionally, Lemierre’s disease is a rapidly progressing infection that results in acute thrombosis. In this report, the nonspecific presentation and failed treatment options that delayed definitive care, led to pulmonary complications, and could have resulted in death are outlined. Eventually, due to the repeat negative blood cultures and cyclic nature of the patient’s fever, the idea to take blood from the patient while febrile led to a diagnosis and rapid treatment that prevented further complications and death.
Conclusions: Early recognition and intervention are crucial in improving Lemierre’s outcomes and decreasing mortality rates. However, the nonspecific nature of early symptoms coupled with the rarity of the disease can make diagnosis challenging. Furthermore, creative thinking in critical cases such as this can lead to better diagnosis and outcomes.