A 32-year-old man with no significant past medical history presented with one day of respiratory distress and fever, sore throat, left neck pain and cough for 3 days. He appeared acutely ill, febrile, tachycardic and tachypneic. Lung exam revealed bronchial breath sounds and crepitation on bilateral lower lobes. Laboratory studies revealed neutrophilic leukocytosis and a normal comprehensive metabolic panel. Rapid strep test and throat culture were negative. Chest X-Ray showed right lower lobe infiltrate and treatment was initiated with ceftriaxone and azithromycin. Patient became more tachypneic and febrile on the next day. He was fluid resuscitated, Zosyn was started and transfered to intensive care unit. Computerized Tomography (CT) chest with contrast showed large loculated pleural effusions with mediastinal lymphadenopathy and multiple cavitary pulmonary nodules. After five days, blood culture came positive for Fusobacterium necrophorum. CT scan of neck showed left internal jugular vein (IJV)thrombosis with inflammation around the carotid space and apical abscess of left maxillary molar. HIV test and Autoimmune panel were negative. Immunoglobulin levels were normal. Bilateral chest tubes were placed with instillation of tPA for drainage of effusion. Pleural fluid studies were consistent with complicated para pneumonic effusions and culture was negative. Chest tubes were pulled out after a repeat CT confirming resolution of pleural effusion. Patient was referred to dental surgeon for drainage of abscess and returned healthy for a 2 month follow up.
Discussion:
Lemierre’s syndrome is characterized by antecedent oropharyngeal infection, fusobacterium septicemia, clinical or radiological evidence of internal jugular vein thrombosis and disseminated foci of infection or septic emboli. It was once called the “forgotten disease” because of its rarity, but apparent increase in its incidence may be due to antibiotic resistance or changes in antibiotic prescription patterns. The presumed hypothesis is that an infection of deep pharyngeal tissue forms an abscess, which ruptures and allows organisms to drain into adjacent pharyngeal space containing the carotid artery and IJV, which can lead to thrombophlebitis resulting in metastatic infections. Treatment includes antibiotics (usually a beta-lactam and metronidazole) for 3-6 weeks and surgical drainage of any abscess. The necessity for anticoagulation remains controversial, but it is often recommended for patients.
Conclusions:
Pharyngitis guidelines focus solely on streptococcal infection. Given the large number of outpatients presenting with pharyngitis, it is possible many cases are diagnosed late in the course when metastatic infection or sepsis becomes apparent. It is important to recognize Fusobacterium necrophorum as an early differential for persistent of worsening pharyngitis in young healthy adults and clindamycin or metronidazole should be added to the treatment.