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An 18-year-old male with no medical history presented to the emergency department (ED) with a 10-day history of fever, sore throat, and cough and a 2-day history of increasing headache, eye pain, a decrease in alertness, and neck pain. The patient was seen in the same ED 6 days earlier with a discharge diagnosis of influenza. The patient’s initial vital signs were as follows: temperature 102.8°F, pulse 123 beats/min, respiratory rate 28 breaths/min, blood pressure 101/59 mm Hg, and peripheral oxygen saturation 96% on room air, improving to 100% on 2 L/min oxygen via nasal cannula.

Physical exam revealed a well-developed, well-nourished African American male in moderate distress due to pain. He was arousable with gentle stimulation but somewhat inappropriate in his verbal responses. He had mild photophobia, nasal congestion, a minimally erythematous posterior oropharynx with cobblestoning, shotty anterior cervical adenopathy, moderate tenderness of his anterolateral neck (right greater than left), and nuchal rigidity. There were coarse rhonchi in the right lung field. There were no other abnormalities on exam.

A noncontrast computed tomography (CT) of the brain was interpreted by an attending radiologist as unremarkable. A lumbar puncture revealed pleocytosis with 21 white blood cells/mL with 88% neutrophils. Chest radiography revealed a right lower lobe infiltrate. Blood work demonstrated an elevated white blood cell count (16.32 × 103/μL) with bandemia (23%) and thrombocytopenia (platelet count 26 × 103/μL). Mild azotemia and transaminitis were also noted.

Given the breadth of organ involvement, in the context of thrombocytopenia and neck pain, the possibility of Lemierre’s syndrome was entertained. A bedside sonogram revealed a mobile thrombus in the right internal jugular (Figure 1 and Video Clip S1).

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Figure 1.  Bedside sonogram illustrating thrombus (asterisk) in the internal jugular vein (ij), lateral to the carotid artery (ca).

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Intravenous ceftriaxone and vancomycin were initially administered, and metronidazole and enoxaparin were administered after the results of the bedside sonogram. The patient was admitted to the pediatric intensive care unit, where magnetic resonance imaging and magnetic resonance angiography revealed right maxillary sinusitis, a right frontal lobe abscess, and extensive cerebral venous thrombosis with extension into the cavernous sinus. An ultrasound performed by the radiology department confirmed the presence of the right internal jugular vein thrombus. Blood cultures were negative. The patient was hospitalized for a total of 7 weeks. Treatment included surgical drainage of the intracranial abscess, intravenous antibiotics, and anticoagulants.

Lemierre’s syndrome refers to septic thrombophlebitis of the internal jugular vein caused by an oropharyngeal infection. The usual organism is Fusobacterium necrophorum. Septic emboli occur most frequently to the lungs, brain, abdomen, and musculoskeletal system. Since the advent of the antibiotic era, Lemierre’s has been dismissed as a relic of the past.1 However, according to recent reports, Lemierre’s syndrome may be experiencing a resurgence.2 This may be attributed to the conservative use of antibiotics for oropharyngeal infections. In the current practice environment, Lemierre’s syndrome generally remains unsuspected until blood cultures return positive for F. necrophorum. Many clinicians are unaware of this potentially lethal entity, and delayed diagnosis has led to increased morbidity and mortality.2 In this case, the use of bedside sonography allowed the expedient diagnosis of Lemierre’s syndrome, enabling prompt diagnosis and treatment in the ED.

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Video Clip S1. Bedside sonogram revealed a mobile thrombus in the right internal jugular.

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