Working Diagnosis:
Postanginal sepsis (Lemierre's syndrome) and multifocal pneumonia.

Treatment:
At the time of discharge from the hospital, her treatment included a transition from intravenous to oral antibiotics, with a one-month course of Augmentin prescribed for septic emboli. Bactrim (trimethoprim-sulfamethoxazole) was added to address multifocal pneumonia. Anticoagulation therapy with Eliquis (apixaban) was initiated for treatment of a left internal jugular vein thrombus. No surgical interventions, such as abscess drainage or thrombectomy, were performed. Her combined OCP was discontinued and non-estrogen containing hormonal contraceptive was initiated.

Outcome:
One factor that makes this case particularly noteworthy is that the athlete participates in ice hockey, a high-contact sport with an increased risk of bleeding. Despite the ongoing controversy surrounding anticoagulation, both vascular surgery and cardiology teams recommended a three-month course of anticoagulation to treat her internal jugular vein thrombus.
She was hospitalized for 12 days and returned to campus three weeks after symptom onset. At that time, a gradual return-to-play protocol was initiated. She began with low- to moderate-intensity exercise and progressed to non-contact activities, all while continuing anticoagulation therapy.
Due to the bleeding risk, contact activities were restricted during this period. Ultimately, she made a full return to play during the final month of the season.

Author's Comments:
Postanginal sepsis, or Lemierre's syndrome, is often underdiagnosed with delayed recognition contributing to a mortality rate of 5 to 18%. It typically affects young, otherwise healthy adults.
Classic presentation begins with unilateral sore throat, neck adenopathy and fever, potentially progressing to pleuritic chest pain. Diagnosis is characterized by recent oropharyngeal infection, internal jugular vein thrombosis, and isolation of anaerobic bacteria, typically Fusobacterium necrophorum, but several other bacteria are listed in the literature.
Prompt treatment is critical. Antibiotics are first-line therapy; some patients also require surgical intervention. Anticoagulation remains controversial but is frequently used.

Editor's Comments:
Common conditions should be considered first in clinical assessment; however, healthcare providers must remain vigilant and maintain clinical curiosity, as patient presentations can evolve rapidly and may signal more serious underlying pathology. It is essential to recognize patients as the foremost experts on their own bodies, positioning clinicians as attentive listeners and advocates. By clearly articulating our clinical reasoning, setting appropriate expectations, and ensuring timely access to follow-up care, we can optimize patient outcomes across the spectrum of acuity and severity.

References:
Allen BW, Anjum F, Bentley TP. Treasure Island (FL): StatPearls Publishing; 2022. Lemierre Syndrome.

David Nygren, Johan Elf, Gustav Torisson, Karin Holm, Jugular Vein Thrombosis and Anticoagulation Therapy in Lemierre's Syndrome. A Post Hoc Observational and Population-Based Study of 82 Patients, Open Forum Infectious Diseases, Volume 8, Issue 1, January 2021

Phua CK, Chadachan VM, Acharya R. Lemierre syndrome-should we anticoagulate? A case report and review of the literature. Int J Angiol. 2013 Jun;22(2):137-42. doi: 10.1055/s-0033-1336828. PMID: 24436600; PMCID: PMC3710021.

Riordan T. Human infection with Fusobacterium necrophorum (Necrobacillosis), with a focus on Lemierre's syndrome. Clin Microbiol Rev. 2007 Oct;20(4):622-59. doi: 10.1128/CMR.00011-07. PMID: 17934077; PMCID: PMC2176048.

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