Case Presentation: A healthy 25-year-old man presented with 8 days of progressively worsening sore throat, fever and neck swelling which were unresponsive to 2 outpatient courses of clarithromycin. 

On presentation, he was febrile, tachycardic, hypotensive, tachypneic and hypoxic. Physical examination was significant for a palpable left-sided neck mass, trismus, and muffled voice. Initial labs revealed a white blood cell count of 26k, creatinine of 1.9mg/dL, and serum lactate of 4.5mg/dL. 

The patient was intubated for airway protection, and started on antibiotics and vasopressors. Ultrasound and CT imaging revealed left tonsillar, peritonsillar, and sublingual abscesses, pulmonary septic emboli, bilateral parapneumonic effusions and left internal jugular (IJ) thrombus. Wound cultures of left tonsillar abscess grew Fusobacterium necrophorum and antibiotics were narrowed to piperacillin-tazobactam. He underwent left IJ ligation and left lower lobe lobectomy and gradually improved, and was discharged home on a prolonged course of antibiotics.   

Discussion: Lemierre’s syndrome is a rare and serious disease entity that primarily affects healthy young adults with an incidence of 1 in 1 million and a mortality rate of 4-12%. It is an oropharyngeal Fusobacterium infection that forms abscesses and IJ thrombophlebitis. This results in bacteremia with septic emboli, commonly to the lungs and joints.

The prevalence of Lemierre’s syndrome has been rising in recent years due to more judicious use of antibiotics for acute pharyngitis. This is also attributed to rising resistance of Fusobacterium to macrolides that are often prescribed for pharyngitis, as illustrated by our patient who was initially treated with clarithromycin. 

Conclusions: Lemierre’s syndrome is a potentially fatal disease that can cause rapid decompensation if untreated. When a young adult presents with worsening symptoms of acute pharyngitis, one must have a high suspicion for this disease for early diagnosis and management.