Working Diagnosis:
Sepsis due to RSV bronchitis, Streptococcus viridans, and Fusobacterium necrophorum causing Left sided Lemierre's syndrome (thrombophlebitis of the left internal jugular vein) with septic emboli

Treatment:
The athlete was discharged after 2 weeks IV Ampicillin/Sulbactam with Amoxicillin/Clavulanate for a total of 6 weeks of antimicrobial therapy as well as therapeutic Enoxaparin for 6 weeks.

Outcome:
Repeat Computed tomography angiography after completion of treatment with resolution of internal jugular thrombosis. The athlete was cleared to start gradual return to play with stationary cardiovascular activity initially progressing to added weight training, then, individual non-contact basketball drills with Full return to basketball at 10 weeks.

Author's Comments:
Lemierre Syndrome is a severe illness caused by Fusobacterium necrophorum which typically occurs in teenagers and young adults (51% in the second decade of life, 20% in the third decade, and 8% in the first decade). Infection originates in the throat typically in pharyngitis, tonsillitis, or dental infection. Infection spreads locally and causes thrombophlebitis of internal jugular vein and may result in septic emboli. While rare, delayed diagnosis leads to higher morbidity and mortality. The team physician is often the first line of contact for athletes with common complaints such as sore throat and cough. A strong athlete-physician relationship can help avoid severe consequences of common complaints with communication and trust, particularly important when caring for diverse patient-athlete populations.

Editor's Comments:
As seen in this case, ear, nose and throat complaints are common amongst the collegiate population and may frequently be encountered by team physicians. While most etiologies of these complaints are benign, less common and more severe pathology should be considered in cases where typical treatments do not result in clinical improvement. Lemierre syndrome or Forgotten Disease is a suppurative thrombophlebitis of the jugular veins, commonly associated with head and neck infections. While most commonly associated with pharyngitis and tonsillitis, cases have been documented with otitis media, infectious mononucleosis, sinusitis, and dental infections. Fusobacterium necrophorum is most commonly implicated in Lemierre syndrome, but may occur with other oropharyngeal pathogens. Clinically, patients may complain of fever, chills, and rigors are commonly seen 4 to 5 days after the inciting infection. Septic emboli may also result in respiratory distress in up to 85 percent of cases with septic arthritis (most commonly of the hip) described in up to 27 percent of cases. Physical examination may be consistent with pharyngitis and tonsillitis with neck swelling variably present. Computed tomography is the preferred imaging modality as ultrasound does not allow for adequate evaluation below the clavicle. Culture targeted antimicrobial treatment for 4 to 6 weeks is recommended with incision and drainage considered for patients with complicating abscess or failure of antimicrobial treatment alone. Anticoagulation with goal of mitigating embolization remains controversial. A high index of suspicion is necessary for timely diagnosis of athletes with recurrent tonsillitis, persistent, or worsening sore throat and fever despite treatment of pharyngitis as delay in antimicrobial therapy has been associated with greater mortality in Lemierre syndrome.

References:
Brook I. Fusobacterial head and neck infections in children. International Journal Pediatric Otorhinolaryngology. 2015 Jul;79(7):953-958.

Eilbert W, Singla N. Lemierre's syndrome. International Journal of Emergency Medicine. 2013 Oct 23;6(1):40.

Karkos PD, Asrani S, Karkos CD, et al. Lemierre's syndrome: A systematic review. Laryngoscope. 2009 Aug;119(8):1552-9.

Kuppalli K, Livorsi D, Talati NJ, Osborn M. Lemierre's syndrome due to Fusobacterium necrophorum. Lancet Infectious Disease. 2012 Oct;12(10):808-15.

Riordan T. Human infection with Fusobacterium necrophorum (Necrobacillosis), with a focus on Lemierre's syndrome. Clinical Microbiology Review. 2007 Oct;20(4):622-59.

Return To The Case Studies List.