A 36-year-old man initially presented to a local clinic with fever, malaise, and upper respiratory symptoms of 2 weeks’ duration; he was diagnosed with a common cold and prescribed antipyretic and analgesic medication. Four days later he presented to our hospital’s emergency department with fever and left chest pain, which he said had started a few days earlier. He had no significant medical history or history of injection drug use.
Chest radiography and computed tomography showed multiple nodular consolidative lesions in both lungs, some of which showed cavitary changes (Figure 1), suggestive of septic pulmonary emboli; however, a fungal etiology could not be completely excluded. Although no clear history of immunocompromise was identified, we could not fully assess the patient’s immune status at presentation. Therefore, empirical antifungal therapy with voriconazole was started and later discontinued when a fungal infection was deemed unlikely. However, further investigation revealed thrombosis of the right internal jugular vein (Figure 2), and blood cultures grew Fusobacterium necrophorum. The patient was diagnosed with septic thrombophlebitis of the internal jugular vein, or Lemierre syndrome.
(A) Chest radiography showed patchy opacities in both lungs. (B) Chest computed tomography showed mostly left-sided nodular opacities, with the dominant lesion showing partial halo sign, ie, a central ground-glass opacity encircled by a rim of consolidation (arrow).
Neck ultrasonography identified thrombus in the right internal jugular vein (arrow).
Meropenem was started at admission. However, the patient’s condition progressed to empyema, requiring mechanical ventilation and placement of chest tubes for drainage. Despite these interventions, his condition did not improve, and surgical debridement was performed twice. He ultimately recovered without significant sequelae, although the hospital course was prolonged, and he was discharged on hospital day 58.
LEMIERRE SYNDROME
Lemierre syndrome lacks a standardized definition, but it is characterized by the presence of bacteremia due to anaerobic Fusobacterium necrophorum (although other oral flora may also be implicated), septic thrombosis of the internal jugular vein, and metastatic infections predominantly affecting the lungs. Pharyngitis along with neck pain or tenderness are often important clinical clues to the diagnosis. Although Lemierre syndrome is rare, it typically occurs in otherwise healthy young adults. Demonstration of internal jugular vein thrombosis is essential for diagnosis.1
The differential diagnosis of Lemierre syndrome includes right-sided infective endocarditis and other causes of septic thrombophlebitis. In recent years, Lemierre-like syndromes associated with methicillin-resistant Staphylococcus aureus infection and conditions such as malignancy have been increasingly recognized.2
In our patient’s case, the neck region was not evaluated on admission, and the diagnosis was established only after right internal jugular vein thrombosis was identified on ultrasonography (Figure 2). Both fungal pneumonia and septic pulmonary emboli may present with multiple nodules and cavitary lesions on chest imaging, making differentiation challenging. Chest imaging revealed multiple bilateral nodular to mass-like opacities, some with cavitary changes, as well as reversed halo–like lesions. In the appropriate clinical context, these findings are consistent with septic pulmonary emboli, which are typically characterized by multiple peripheral nodules, with or without cavitation, and subpleural opacities.3
Chest imaging findings alone are insufficient to establish the diagnosis of Lemierre syndrome. The necessity of routinely including the neck in imaging studies remains unclear, but in the appropriate clinical context—such as a previously healthy young patient with a preceding oropharyngeal infection and chest findings suggestive of septic pulmonary emboli—contrast-enhanced neck imaging should be performed to evaluate for internal jugular vein thrombosis.4
The mainstay of treatment is prolonged antibiotic therapy, typically for 4 to 6 weeks. Optimal treatments include beta-lactam antibiotics in combination with metronidazole, a beta-lactam combined with a beta-lactamase inhibitor, or a carbapenem; these are commonly used to ensure adequate coverage of anaerobic pathogens.4 The role of anticoagulation remains controversial, as no clear survival benefit has been demonstrated.5 Surgical intervention may be required in cases complicated by abscess formation.
DISCLOSURES
The authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.
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REFERENCES
- 1↵Kuppalli K, Livorsi D, Talati NJ, Osborn M. Lemierre’s syndrome due to Fusobacterium necrophorum. Lancet Infect Dis 2012; 12(10): 808–815. doi:10.1016/S1473-3099(12)70089-0
- 2↵Carreras X, Salcedo AS, Ponce-Rosas L, Gonzales-Zamora JA, Diaz N, Alave J. Lemierre-like syndrome after soft tissue infection due to methicillin-resistant Staphylococcus aureus: a case report and literature review. Medicine (Baltimore) 2024; 103(7):e37006. doi:10.1097/MD.0000000000037006
- 3↵Swain S, Ray A. Septic pulmonary embolism. BMJ Case Rep 2021; 14(10):e246306. doi:10.1136/bcr-2021-246306
- 4↵Carius BM, Koyfman A, Long B. High risk and low prevalence diseases: Lemierre’s syndrome. Am J Emerg Med 2022; 61:98–104. doi:10.1016/j.ajem.2022.08.050
- 5↵Senda A, Fushimi K, Morishita K. Anticoagulation treatment in patients with septic thrombophlebitis of the internal jugular vein. West J Emerg Med 2025; 26(6):1590–1597. doi:10.5811/westjem.47130
