Working Diagnosis:
Lemierre's Disease (Forgotten Disease: pharyngitis associated with thrombosis of the internal jugular vein with subsequent septic emboli

Treatment:
The patient received incision and drainage twice during the admission. He received ampicillin-sulbactam (Unasyn) and clindamycin which were changed to piperacillin-tazobactam (Zosyn) after 3 days per the infectious disease physician. The patient was hypertensive and was started on lisinopril. He also developed bradycardia and sinus pauses which did not require any interventions. Both the conditions were managed by a Cardiologist.
To reduce the risk of septic thromboembolism, he was anticoagulated using warfarin (Coumadin) for 3 months after consultation with a hematologist.

Outcome:
Despite his serious condition, he improved with early intervention and prompt diagnosis. Chest X-ray after one week showed improvement of consolidation. His cervical incision healed with no drainage. The patient was discharged home after ten days, with plan for a total of 6 weeks of intravenous antibiotics. CT scan of the neck after one month documented resolution of the internal jugular vein thrombosis with scarring.

Author's Comments:
By the time the patient was discharged, the football season was over. He decided to go home. He presented for out-patient follow up within a few weeks of hospital discharge with complete resolution of his symptoms.

Editor's Comments:
This previously healthy young adult presented with prolonged symptoms of neck pain with pharyngitis. Studies in adolescents and young adults indicate that Fusobacterium necrophorum can be the etiology for pharyngitis in up to 10% of cases(1). As Dr. Centor reminds us, pharyngitis typicaly has a 3 to 5 day duration. This athlete was promptly hospitalized for "red flag" signs of neck swelling and toxicity and for prolonged, worsening symptoms. F. necrophorum is resistant to macrolide antibiotics. Consider F. necrophorum in the differential diagnoses of streptococcal negative pharyngitis and treat with a penicillin or cephalosporin (clindamycin is a reasonable alternative if penicillin allergy is present). Admit patients with "red flags" since sepsis and Lemierre's syndrome are potential catastrophic sequelae of this infection.

References:
(1) Centor RM. Expand the Pharyngitis Paradigm for Adolescents and Young Adults. Ann Intern Med. 2009; 151:812-815.

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