Streptococcal Toxic Shock Masking Lemierre's Syndrome

We report a case of a previously healthy woman presenting with septic shock unresponsive to seven litres of intravenous fluid resuscitation, broad-spectrum antimicrobials, necessitating admission to intensive care. The history and clinical presentation suggested streptococcal toxic shock syndrome (STSS), and group A beta-hemolytic streptococcus (GAS) was isolated from blood cultures. Persisting leg weakness, neck and spinal pain led to an MRI, which showed an inflammatory process on the right side of the neck, confirmed by CT angiogram as right internal jugular venous thrombosis. The triad of cervical lymphadenopathy, internal jugular venous thrombosis and sepsis is a classical feature of Lemierre's syndrome, but here caused by a rarely associated pathogen, namely GAS. Our case illustrates the necessity for investigating all possible foci of invasive GAS (iGAS) and repeating a careful clinical examination if not improving.