Biphasic Clinical Course Revealing Lemierre's Syndrome Following Acute Pharyngotonsillitis: A Case Report

Lemierre's syndrome is a life-threatening septic thrombophlebitis that typically follows an oropharyngeal infection and is most commonly caused by Fusobacterium necrophorum (F. necrophorum). We report a case of a previously healthy woman in her 20s who developed septic shock and acute kidney injury after a recurrent episode of acute pharyngotonsillitis. She was initially treated at a local clinic with a short course of oral third-generation cephalosporin for presumed group A streptococcal pharyngotonsillitis, resulting in temporary clinical improvement. However, she subsequently experienced a recurrence of fever and sore throat, necessitating emergency hospitalization. She was treated immediately with intensive intravenous ampicillin/sulbactam and vasopressor support. A contrast-enhanced CT several days later demonstrated septic pulmonary emboli, and blood cultures subsequently yielded F. necrophorum. Although internal jugular vein (IJV) thrombosis was not evident, a diagnosis of Lemierre's syndrome was established based on antecedent pharyngotonsillitis, F. necrophorum bacteremia, and metastatic septic emboli. This report suggests that short-course oral cephalosporin therapy for presumed group A streptococcal pharyngotonsillitis does not necessarily prevent the subsequent development of invasive F. necrophorum infection. It may also delay the recognition of Lemierre's syndrome.