Case Presentation: A 19 year-old college student presented with fevers, chills, and a sore throat for the past 7 days. She had no significant past medical history and was healthy at baseline. She denied any illicit or intravenous drug use. Her vitals were notable for a temperature of 102.4F and heart rate 115 bpm. On exam, her oropharynx was unremarkable. She had palpable anterior chain cervical lymph nodes bilaterally that were non-tender. Notable laboratory values included a white blood count of 3,100 per microliter with 30% bands. A rapid streptococcal, mono spot, and HIV test were all negative. To further evaluate for a possible retropharyngeal abscess, a CT neck revealed diffuse prominent cervical lymph nodes, and apical pulmonary opacities. CT chest to further elucidate these findings revealed multifocal peripheral opacities concerning for septic emboli. A transthoracic echocardiogram was unrevealing for any valvular vegetations. 24 hours later, her anaerobic blood cultures grew Fusobacterium necrophorum. Given this unique organism that is associated with Lemierre’s syndrome and internal jugular thrombophlebitis, an upper extremity ultrasound revealed an acute thrombus in the left internal jugular vein. She was placed on a 4-week course of intravenous ceftriaxone and metronidazole with complete resolution of the left internal jugular thrombus on repeat ultrasound 2 weeks later.

Discussion: Lemierre’s syndrome has been coined as the “Forgotten Disease” since it is rarely encountered in the era of antibiotics with an estimated worldwide incidence of 0.8 per million persons per year. Lemierre’s syndrome is characterized by a history of a recent oropharyngeal infection that is complicated by extension into the lateral pharyngeal spaces of the neck with subsequent septic thrombophlebitis of the internal jugular vein, and septicemia typically with Fusobacterium necrophrum. Although the most common pathogen responsible is Fusobacterium necrophorum, an obligate anaerobic, gram-negative bacilli, other organisms have also been reported in other case studies. Septic thrombophlebitis of the jugular vein, one of the key characteristics of this syndrome, leads to thrombosis and septic emboli via hematological spread to other organs, with the most frequent metastatic site being the lungs. Treatment includes a prolonged course of antibiotic therapy, but hospitalist may encounter the dilemma if anticoagulation is warranted. There are currently no clear guidelines for the use of anticoagulation in Lemierre’s syndrome. Small retrospective studies suggest that anticoagulation in Lemierre’s syndrome does not affect thrombosis outcomes, compared to treating with antimicrobial therapy alone. Some authors, however, recommend anticoagulation after 7 days of adequate antimicrobial therapy if there is progression of the thrombus given the potential for retrograde progression into the cavernous sinus.

Conclusions: Hospitalists should keep the diagnosis of Lemierre’s syndrome on the differential when encountered with the triad of oropharyngeal sepsis and bacteremia, internal jugular vein thrombophlebitis, and metastatic infection. Additionally, anticoagulation therapy is generally not strongly indicated, unless there is concern for progression of the thrombus. We recommend potentially re-imaging the thrombus with ultrasound 1-2 weeks after start of antimicrobial therapy to help guide this decision.

IMAGE 1: CT chest demonstrating septic emboli