(516) Throat Pain in GenZs: Are Antibiotics Enough?

Introduction: Lemierre's syndrome is an illness resulting from a lack of antibiotic therapy in young patients. Thrombophlebitis of the internal jugular vein is noted with bacteremia linked to a recent infection of the oropharynx.

Description: A vicenarian male presented with chills for 3 days with associated headaches, fever, congestion, rhinorrhea, and cough. This 22-year-old was afebrile, hypotensive with tachycardia, and tachypnea. His complete blood count showed leukocytosis and thrombocytopenia. He had an acute kidney injury and his total bilirubin was elevated at 3 mg/dL. On day 2 of admission, he endorsed neck pain and photophobia with a headache. He had similar symptoms while he was incarcerated and had sick contacts. Blood cultures showed gram-negative bacteremia, negative hepatitis A/B, HIV, MRSA, and blood parasite smear.
However, leukocytosis worsened despite ceftriaxone and azithromycin being given. A positive Brudzinski's sign was noted however, due to thrombocytopenia, a lumbar punction was deferred. A CT chest showed multifocal pneumonia with lesions concerning for early cavitation. He was hypoxic and was placed on oxygen by nasal cannula. The patient was started on ceftriaxone, vancomycin, and azithromycin. He developed a fever and worsening hypoxia requiring oxygen via a high-flow nasal cannula. CT of the neck showed right submandibular sialoadenitis with thrombosis of the right external and internal jugular veins consistent with Lemierre's syndrome. He had septic emboli to the lungs. A lumbar puncture was negative for meningitis. He was continued on ceftriaxone and started on Piperacillin/Tazobactam. His leukocytosis continued to worsen with tachycardia and tachypnea for which he was placed back on oxygen via a high-flow nasal cannula. A repeat CT chest showed a new right lower lung cavitary lesion measuring 8 x 8 mm. Quantiferon ruled out tuberculosis. The infectious disease team started Ampicillin/Sulbactam for 14 days with oral Cephalexin and Metronidazole for 2 weeks. He improved clinically and was discharged.

Discussion: Lemierre syndrome is a rare condition with approximately 3.6 cases per million every year. It should be suspected in young, healthy patients with pharyngitis followed by sepsis, pneumonia, or neck pain.