Working Diagnosis:
The final working diagnosis was Septic Thrombophlebitis of the Internal Jugular Vein (Lemierre's Syndrome).

Treatment:
The patient was treated with broad-spectrum antibiotics, including Vancomycin, Piperacillin-Tazobactam, and Clindamycin, and these were narrowed after cultures resulted. She required wound debridement in the operating room twice with otolaryngology for source control. She was additionally anticoagulated with Heparin while she was inpatient and Apixaban outpatient after discharge from the hospital.

Outcome:
The collegiate swimmer had an eight-day intensive care admission and underwent two neck abscess drainage and debridement surgeries with otolaryngology during this time. She continued to improve and was downgraded to the floor and discharged home in stable condition. She continued ceftriaxone through her PICC line and metronidazole orally until follow-up with infectious disease. She was started on apixaban for two months until follow-up with vascular surgery. She had to medically withdraw from the Fall semester, but after a long recovery, she successfully returned to swimming in the Spring semester and fully returned to sport approximately 5 months following the onset of her illness. During her return to play, she experienced unilateral right arm swelling, but had a negative DVT ultrasound. She has otherwise remained symptom-free and is planning to compete in the upcoming season.

Author's Comments:
Lemierre's syndrome is a septic thrombophlebitis of the internal jugular vein. It is a rare, but life-threatening condition that most commonly affects otherwise healthy young adults and adolescents with a mean age of 20 years. The initial infection originates in the oropharynx with local spread to the internal jugular vein. Bacterial endotoxins cause platelet aggregation and resultant thrombus formation in the internal jugular vein. The septic thrombus can lead to emboli affecting any organ system, but in almost all cases will go to the lung, causing septic pulmonary emboli. This syndrome is difficult to diagnose and usually requires multiple provider visits before the diagnosis is clinched with CT neck with IV contrast. This case highlighted the difficulties of diagnosis as the swimmer was initially rather well-appearing, but decompensated over the course of several days. Additionally, Epstein Barr Virus is an uncommon infection to precede Lemierre's Syndrome, and many of this patient's symptoms initially could have been attributed to mononucleosis infection and sequelae. The most commonly isolated bacteria in Lemierre's Syndrome is Fusobacterium necrophorum, but this organism was not isolated in this case. Management includes broad-spectrum antibiotics and may potentially require surgery. Anticoagulation is controversial, but was used in this case due to the extensive clot burden in her internal jugular veins. Medical professionals need to have a high index of suspicion in patients presenting with neck pain and stiffness with a preceding pharyngitis.

Editor's Comments:
Lemierre's syndrome is a rare, elusive complication of bacterial pharyngitis or tonsillitis. Infection extends into the lateral pharyngeal spaces of the neck with development of subsequent septic thrombophlebitis of the internal jugular vein. Yikes! Persistent fevers, neck tenderness, and swelling are early clinical signs that pharyngitis has extended beyond the oropharynx. A bigger clue is unilateral tenderness and swelling at th mandible, "cord sign". The cord sign indicates internal jugular thrombosis present. A close exam of the neck, including the suprasternal and supraclavicular regions is imperative to identify potential cord sign.

References:
1. Allen BW, Anjum F, Bentley TP. Lemierre Syndrome. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499846/
2. Becker JA, Smith JA. Return to play after infectious mononucleosis. Sports Health. 2014 May;6(3):232-8. doi: 10.1177/1941738114521984. PMID: 24790693; PMCID: PMC4000473.
3. Lee WS, Jean SS, Chen FL, Hsieh SM, Hsueh PR. Lemierre syndrome: A forgotten and re-emerging infection. J Microbiol Immunol Infect. 2020 Aug;53(4):513-517. doi: 10.1016/j.jmii.2020.03.027. Epub 2020 Apr 4. PMID: 32303484.
4. Carius BM, Koyfman A, Long B. High risk and low prevalence diseases: Lemierre's syndrome. Am J Emerg Med. 2022 Nov;61:98-104. doi: 10.1016/j.ajem.2022.08.050. Epub 2022 Aug 30. PMID: 36058204.

Return To The Case Studies List.