Case 4

A 29-year-old man with no significant past medical history presented to the emergency room with a high fever, chills, sore throat, cough, shortness of breath, and diffuse myalgias in April 2020. He was found to be febrile to 107°F and tachycardic with a HR of 140. WBC count was 38. Covid testing was negative. Chest X-ray showed diffuse patchy opacities. CT chest was performed, which showed diffuse bilateral lung nodules, mostly peripherally located, some of them with apparent cavitation.

A: Bilateral peripheral lung nodules should make you think of an embolic phenomenon, usually endovascular infection such as endocarditis or metastatic cancer.

Blood cultures were obtained and grew fusobacterium necrophorum and streptococcus anginosis in 4/4 bottles on day 1. The patient was started on piperacillin/tazobactam. TTE was unremarkable and did not show signs of endocarditis. TEE was also unremarkable. The patient’s symptoms improved over the next couple days, but he was still feverish on hospital day 3.

You review the chart and realize an important test is missing from this patient’s workup.

A: Duplex ultrasound of the neck veins.

Neck vein evaluation with ultrasound revealed a large clot in the right IJ. Antibiotics were narrowed to ampicillin/sulbactam.

Tap for the Diagnosis

Lemierre’s syndrome

(septic thrombophlebitis of the internal jugular vein)

Outcome: The patient gradually improved with antibiotics. His course was complicated by bilateral pleural effusions requiring chest tube drainage, but he made a full recovery.  

Learning Points

  • Fusobacterium bacteremia and sore throat should raise suspicion for Lemierre’s syndrome.

  • Diffuse peripheral lung nodules should raise concern for endovascular infection and metastatic cancer.

  • Consider epiglottitis, Lemierre’s syndrome, and deep-space neck infections in ill-appearing patients presenting with a severe sore throat accompanied by non-specific symptoms.

Page Last Updated: July 19, 2022

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Headshot of Eric Tanenbaum, MD · Assistant Professor, WSU College of Medicine; Nocturnist, Swedish Hospital Medicine
Eric Tanenbaum
MD · Assistant Professor, WSU College of Medicine; Nocturnist, Swedish Hospital Medicine
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