Lemierre's syndrome: Acute oropharyngeal infection leading to septic thrombophlebitis of the internal jugular vein with pulmonary septic emboli

Case presentation: A 12-year-old boy with no significant past medical imaging presented to the emergency department with 1 week of fever, sore throat, and left neck swelling. The patient was febrile with a leukocytosis and subsequently underwent contrast-enhanced computed tomography (CT) for further evaluation. Imaging findings: Contrast-enhanced CT demonstrated a hypodense lesion with peripheral rim enhancement in the left tonsil, consistent with an abscess. There was extensive surrounding inflammation and surrounding edema. Additionally, there were central filling defects in the left internal and external jugular veins consistent with thrombosis. The apex of the lungs found bilateral peripherally based lung nodules that represented septic emboli. This was confirmed with subsequent dedicated CT chest. Discussion: The constellation of peritonsillar abscess with associated thrombophlebitis of the jugular veins and pulmonary septic emboli is Lemierre's Syndrome. This is an uncommon and important diagnosis as it is life-threatening even with aggressive treatment (8% mortality) and the radiologist can often be the first to suggest the diagnosis. Classically the offending agent is the anaerobic gram-negative rod, Fusobacterium necophorum, although polymicrobial bacteremia is seen in up to a third of the cases. Cultures in the current case grew Streptococcus constellatus, a rare cause of Lemierre's Syndrome. Lemierre's Syndrome was first described in 1936 and is less commonly seen with the advent of antibiotics and thus also referred to as the ‘Forgotten Disease’, although there has been a reemergence more recently likely due to antibiotic resistance. It is most commonly seen in immunocompetent teenagers and young adults, more typically in males. Treatment includes antibiotics plus or minus abscess drainage and/or anticoagulation. Conclusions: Lemierre's Syndrome has the classic imaging triad of ipsilateral pharyngeal fullness and neck vein thrombosis with pulmonary septic emboli. Our patient underwent a prolonged course of intravenous antibiotics with resolution of infection.