Case Presentation: A 20-year-old otherwise healthy male presented with a three day history of fever, sore throat, and myalgias. He was given supportive care and discharged home after testing negative for strep. He returned three days later with pleuritic chest pain, neck and ear pain, and had developed trismus. On arrival, his heart rate was 140 with a blood pressure of 88/56. He appeared ill and was diaphoretic. There was no cervical adenopathy or evidence of tonsillar swelling but he demonstrated an interincisor opening of 8mm. The left side of his neck was diffusely tender to palpation. He had scattered rhonchi bilaterally with accessory muscle use. There were no neurological deficits. His WBC was 12.5 k/uL and platelets 22 k/uL. His lactate was 2.4 mmol/L and procalcitonin 62 ng/mL. A contrasted neck CT showed left palatine tonsillitis without abscess and thrombosis of the left anterior jugular vein. A chest CT with contrast demonstrated multiple cavitary lesions throughout the lungs and evidence of right heart strain. Transthoracic echo demonstrated a right-to-left shunt consistent with a patent foramen ovale (PFO) with no evidence of valvular vegetations. Due to worsening headache, MRI head was performed and demonstrated a septic embolus to the corpus collosum. Blood cultures on admission grew Fusobacterium necrophorum. The patient was diagnosed Lemierre’s Syndrome complicated by a paradoxical embolus to brain. He was ultimately treated with Meropenem.
Discussion: Acute pharyngitis is encountered in many clinical settings. When symptoms are refractory to treatment and systemic signs of infection develop, it should raise suspicion for Jugular Vein Suppurative Thrombophlebitis, or Lemierre’s Syndrome. Improvements in antimicrobial stewardship has led to a recent increase in the incidence of Lemierre’s Syndrome and hospitalists should be aware of this “forgotten” disease. Lemierre’s Syndrome typically presents in the 2nd and 3rd decade of life following an episode of acute pharyngitis. Following an initial infection, thrombophlebitis of the internal jugular vein can develop. This can lead to the development of septic emboli, most often resulting in pulmonary manifestations. Additionally, and as demonstrated in this case, the presence of a PFO can allow for paradoxical emboli. Fusobacterium necrophorum is the most common pathogen seen in Lemierre’s Syndrome and is often susceptible to beta-lactams, metronidazole and carbapenems. Meropenem was selected in this patient due to improved CNS penetration. The role of anticoagulation remains controversial in Lemierre’s Syndrome and no randomized controlled trials have been performed. Anticoagulation was deferred in this patient.
Conclusions: Lemierre’s Syndrome is characterized by internal jugular thrombophlebitis preceded by an episode of acute pharyngitis. Embolization occurs most often to the lungs but can result in paradoxical emboli in the presence of a PFO.