Working Diagnosis:
The working diagnosis for this athlete was Lemierre Syndrome (LS), or septic thrombophlebitis of the internal jugular vein.

Treatment:
The patient was promptly started on broad-spectrum IV antibiotics when LS was suspected. Once confirmed, Infectious Disease and Vascular surgery were consulted for treatment recommendations. The patient was treated with six weeks of continuous penicillin G to treat his infection. He was started on apixaban due to his clot burden and no evidence in high-risk areas of clot such as the brain or spleen. He continued apixaban for three months, after which he was transitioned to aspirin 81 mg. He tolerated the treatment well with near-full resolution of symptoms.

Outcome:
The athlete in this case underwent a slow return to activity after recovery from his acute illnesses. This athlete's LS did not slow his return to play as his heart failure recovery was longer than his recovery from LS. He ultimately returned to competition seven months after his illness after titrating off all medications and completing full cardiac clearance.

Author's Comments:
Lemierre syndrome is a rare but serious condition stemming from either a primary F. necrophorum oropharyngeal infection or a secondary infection after an initial viral or bacterial insult. (1) In this case, the athlete could have sustained either a primary or secondary infection, (2) though a secondary infection is favored given prolonged symptoms prior to his first hospitalization and return of positive coxsackievirus titers during that admission. LS should be considered in any young adult who develops fevers, neck pain, and trismus after an upper respiratory infection. Early diagnosis and treatment are imperative to decreasing metastatic and local complications as well as fatality. Treatment includes decisions about antibiotics and anticoagulation that are tailored to each patient individually. (2)

Editor's Comments:
This case highlights an uncommon but serious illness that may be missed in the training room setting. Lemierre syndrome should be considered in any athlete with persistent sore throat or mouth, neck pain and systemic symptoms. This may be isolated or following a seemingly benign oropharyngeal infection.

References:
1. Centor, Robert M., and Ralph Samlowski. "Avoiding sore throat morbidity and mortality: when is it not "just a sore throat?"." American family physician 83.1 (2011): 26-28.
2. Lee, Wen-Sen, et al. "Lemierre's syndrome: a forgotten and re-emerging infection." Journal of Microbiology, Immunology and Infection 53.4 (2020): 513-517.

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