Case Presentation:
A 30‐year‐old African American woman with an unremarkable medical history presented to the emergency room with 14 days of progressive sore throat, high fever, malaise, voice changes, and dysphagia to solids. Positive findings on examination include sinus tachycardia 140 per minute, dry oral mucosa, and erythema in the left tonsillar pillar. There was edema and tenderness in the left submandibular area. Creatinine was 1.94 mg/dL, AST 431 U/L, and ALT 149 U/L. The patient was hydrated with IV normal saline and kept in observation for 16 hours. A dose of ceftriaxone 1 g IV was given after blood cultures were drawn. The patient was discharged home with amoxicillin‐clavulanate orally. She was advised to have a follow‐up in the ENT outpatient clinic. She presented 5 days later to the scheduled follow‐up with persistence of previously described symptoms in addition to nausea, bilious vomit, and pleuritic chest pain. A left‐sided neck induration was also noticed. Blood cultures sent were positive for Fusobacterium species. Neck duplex ultrasound showed thrombosis of the mid to distal left internal jugular vein and external jugular anterior branch with adjacent enlarged lymph node at level 3 and left supraclavicular lymph node. The patient was admitted to the hospital with a diagnosis of Le‐mierre's disease and started on clindamycin 600 mg IV every 8 hours and Dalteparin. Neck CT confirmed the duplex findings. A chest CT scan demonstrated several peripheral pulmonary nodules with patchy air‐space process in the lingula and cavitary process in the superior segment of the right lower lobe without evidence of pulmonary embolism. Transthoracic echocardiogram was unremarkable. Kidney function normalized as well as liver function. The patient completed 14 days of IV clindamycin and was sent home on amoxicillin‐clavulanate for 6 weeks and warfarin 5 mg for 6 months. Follow‐up with the infectious diseases and anticoagulation clinic was set as an outpatient.
Discussion:
Lemierre's disease, also known as the forgotten disease, is a rare but lately most frequently diagnosed condition compromising previously young, healthy individuals characterized by postanginal bacteremia and thrombosis of the internal jugular vein. Caused mainly by Fusobacterium necrophorum, this condition if untreated can lead to sepsis, multiple organ dysfunction, and death. The diagnosis requires a high clinical suspicion. There is no consensus regarding the need for anticoagulation in Lemierre's disease. The recommended length of antibiotic treatment is at least 6 weeks.
Conclusions:
Lemierre's disease is a potentially lethal disease that requires a high clinical suspicion to confirm the diagnosis. The hospitalist will face the dilemma of deciding the extent of the diagnostic workup and length of antibiotic treatment as well as the need for and duration of anticoagulation.
Author Disclosure:
A. F. Soto, none.