Lemierre's Syndrome: A Cloaked Dagger

Abstract

Lemierre's syndrome is a condition characterized by septicemia, with bacteremia, thrombophlebitis of the internal jugular vein (IJV), and septic embolization to distant organs following a recent upper respiratory infection (URI). Fusobacterium necrophorum, an anaerobic Gram-negative rod, has been mostly implicated as the causative organism of this condition that tends to affect healthy teenagers and young adults. While once regarded as a disease of old, it has seen a resurgence in recent times, possibly due to antibiotic stewardship and current trends of reduced antibiotic use for URIs. It is important that the modern physician has a high index of suspicion, as well as the characteristic presentation of this potentially fatal illness. Current treatment guidelines are centered on the use of appropriate antibiotics, drainage of purulent collections when possible, and, in some situations, anticoagulants have been utilized. This study describes a case of a young lady who presented with symptoms of chest pain and deteriorating oxygen saturations following recent treatment for acute tonsillitis.

Keywords: fusobacterium necrophorum; internal jugular vein thrombophlebitis; lemierre's syndrome; septic thrombophlebitis; tonsilitis.

Figure 1. Longitudinal sonogram of the left neck

Sonogram demonstrates a hypoechoic, non-occlusive thrombus within a dilated left internal jugular vein (arrow A). Patent internal jugular vein is shown cranial to the thrombus (arrow B), and common carotid artery (arrow C).

Figure 2. Postcontrast CT scan of the neck at the tongue base/tonsillar level

There is symmetrical palatine tonsillar enlargement. No focal fluid collection is present, but bubbles of gas can be seen within the left palatine tonsil (arrow) consistent with infection with a gas-forming organism.

Figure 3. Coronal CT of the neck

Coronal postcontrast CT through the left internal jugular vein confirms linear low-density thrombus (arrows).

Figure 4. Axial CT postcontrast at the level of the upper neck

This confirms a rounded focus of low attenuation in the left internal jugular vein (arrow A) in keeping with thrombus. Note normal enhancing right internal jugular vein (B).

Figure 5. Axial CT pulmonary angiogram

Axial CT image through the lungs at the level of the carina, lung window setting, showing multiple ill-defined soft tissue nodules in both lungs and sub-pleura. Multiple thick-walled lung cavitations can be seen (arrows), consistent with septic emboli.