Case Presentation: A 25 year old woman with history of asthma presented to the emergency department with one week of sore throat, cough, shortness of breath, nausea, vomiting, and diarrhea. Upon arrival, she was hypotensive, tachycardic, tachypneic, febrile, and was found to have leukocytosis, elevated lactate, procalcitonin, and creatinine prompting concern for septic shock. She received appropriate resuscitation but was unresponsive to IV fluids necessitating pressors. Blood cultures were submitted, and empirical antibiotics administered. Imaging revealed multiple cavitary lung nodules, blood cultures grew Fusobacterium necrophorum, and CT and ultrasound of the neck did not reveal IJV thrombophlebitis but did show peritonsillar abscess. In addition, she developed soft tissue abscess of right shoulder with acromium osteomyelitis followed by septic arthritis of the left hip several weeks into treatment. She eventually recovered with antimicrobial treatment duration of 6 weeks.

Discussion: Lemierre’s disease, historically rare and termed “the forgotten disease”, is now a re-emerging infectious disease with occurrence of approximately 1-2 cases/million/year. The characteristic thrombophlebitis and hematogenous spread results in a wide range of complications. Lung involvement is seen in over 90% of cases with large joints being next most common at approximately 20% of cases. Other affected organs include heart, liver, skin/soft tissue, brain, and bone. Of note, both soft tissue infection and osteomyelitis are seen in <3% of cases. Most definitions of Lemierre's disease include IJV thrombophlebitis, but on rare occasion other vessels may be involved. Over 50% of patients require ICU admission with high mortality if not diagnosed and treated in a timely manner, thus the importance of increased awareness by hospitalists and early recognition of this syndrome is clear.

Conclusions: Lemierre’s syndrome is a rare, potentially fatal complication of pharyngitis. The classic syndrome is characterized by acute oropharyngeal infection with Fusobacterium necrophorum resulting in septic thrombophlebitis of the internal jugular vein (IJV), subsequent septicemia, and septic embolization to the lungs. If not recognized and treated early, it can present with high mortality and thus is imperative that hospitalists be aware of this syndrome. We present an atypical case of severe pharyngitis, peritonsillar abscess, F. necrophorum bacteremia, multiple pulmonary cavitary lesions, shoulder abscess, osteomyelitis of the acromion, and late septic arthritis of the hip without obvious IJ thrombophlebitis.