A 40‐year‐old woman with no past medical history presents to the hospital complaining of severe neck pain, headache, fever, malaise, and shortness of breath with pleurtic chest pain. Her symptoms were preceded by a sore throat of increasing severity for 48 hours. Two other family members had experienced a similar sore throat without the further escalation of symptomatology as experienced by the patient. Physical exam revealed a septic patient with marked fever, right‐sided tonsillar exudate, and exquisite tenderness to palpation to enlarged cervical lymph nodes. Lab studies were consistent with a leukocytosis with neutrophilic predominance and GAS rapid assay positivity. CT Neck demonstrated tonsillar enlargement and lymphadenopathy without any vascular involvement. Chest x‐ray revealed patchy airspace disease in the bilateral lung fields that was supported by findings of bilateral and diffuse ground glass opacities on CT Chest concerning for embolic process. The patient’s severity of illness, focal neck exam, GAS assay positivity, and apparent pulmonary emboli provided a high clinical suspicion of possible suppurative thrombophlebitis. Further imaging with vascular ultrasound of the neck demonstrated a thrombus of the right internal jugular vein. Blood cultures revealed coagulase‐negative staphylococcus which were determined to be contaminant. The presence of the severe pharyngitis with concurrent embolic pattern of lung disease and the presence venous thrombus provided for a diagnosis of Lemierre’s syndrome. The patient received appropriate antibiotic treatment with IV ampicillin / sulbactam with rapid improvement in symptoms.
Lemierre’s syndrome is a form suppurative thrombophlebitis of the internal jugular vein that is preceded by pharyngitis typically with tonsillar involvement and involving young, immunocompetent patients. The direct extension of inflammation from the pharynx into the neighboring carotid sheath results in direct inoculation of the bloodstream with oropharyngeal flora. An infected thrombus forms and results in embolic phenomenon with patients commonly presenting with infiltrative lung process consistent with septic emboli. A high index of suspicion must be had for the possibility of Lemierre’s syndrome in a patient with high fever, antecedent pharyngitis, and pulmonary emboli. The most useful radiologic tools for visualizing a possible internal jugular thrombus include high resolution CT of the neck and vascular ultrasound. A treatment regiment should focus on removing the infectious burden with specific therapy targeting native oropharyngeal flora – including anerobes and a limited number of gram‐positive species (i.e. streptococcal, et al) – for at least two‐to‐four weeks. Many of the causative organisms are fastidious bacteria that require several days to properly identify, and treatment delay for organism identification should not occur. As evidenced by this patient case, rapid diagnosis and treatment of Lemierre’s syndrome can prevent significant morbidity and mortality.
A high pre‐test probability of this diagnosis is key to initiating appropriate treatment as rapid clinical decline may result with a delay in care. A high index of suspicion should be had for any patient with the triad of fever, severe pharyngitis, and embolic phenomenon for Lemierre’s syndrome regardless of age, radiography, or microbiology results.
To cite this abstract:Davies L, Atkinson T, Katz M. Lump in the Throat. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 400. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/lump-in-the-throat/. Accessed March 28, 2020.