Background Lemierre’s syndrome is characterised by a clinical triad of oropharyngeal infection with bacteraemia, thrombophlebitis of internal jugular vein and distant metastatic abscesses. In England and Wales the reported incidence is one per million persons per year. The infrequency of its occurence makes it a really formidable diagnostic challenge. Diagnosis usually only becomes apparent with isolation of Fusibacterium in blood culture, the results of which can be delayed up to seven days.

Case report A 16 year old girl, previously fit and well, presented acutely with a 9 day history of sore throat and cervical lymphadenopathy, 2 day history of high grade fever, dry cough and 1 day history of breathlessness with pleuritic left sided chest pain. She had received treatment with oral clarithromycin from her GP the previous 48 hours with no improvement. Her observations on admission were T=38.9C, BP 116/65 mmHg, HR=140/ min, RR=34/min, SpO₂=94% in air. On examination she was not cyanotic but looked restless and was tachypnoeic with pleuritic chest pain. Breath sounds were harsh with reduced air entry on the right side. Throat was red but no evidence of tonsillar exudate. She had bilateral non-tender cervical lymphadenopathy. Remaining systematic examination were unremarkable including neurological, abdominal, cardiovascular and muskulo-skeletal assessments. Initial investigations confirmed an infective cause with CRP of 308 mg/L, neutrophilia of 14 × 10 ⁹/L and right middle lobe consolidation seen on chest radiograph (CXR). Glandular fever screen was negative. Peripheral blood culture result awaited.. She was commenced on intravenous (iv) Co-Amoxiclav for the right sided pneumonia. Despite iv antibiotics her clinical picture did not improve. She continued to spike high grade fever and progressed to develop and oxygen requirement of 2 L/min to maintain oxygen saturations above 92%. She complained of more neck and chest pain and seemed more breathless. The degree of breathlessness was disproportionate to the minimal oxygen requirement and work of breathing. A repeat CXR was requested which showed deterioration with worsening consolidation and evidence of pleural effusion or empyema. Blood gases were satisfactory through out. On advice from microbiology antibiotic was changed to iv Tazocin as the preliminary blood culture report was positive for gram negative rods. Despite receiving two doses of Tazocin, she continued to deteriorate with increasing chest pains and marked breathlessness. Concern of a pulmonary embolus was increasing. An urgent contrast computed tomography (CT) chest and neck were requested. CT scan of the chest showed bilateral lower lobe consolidation, right sided pleural effusion with loculation of the right horizontal fissure. Surprisingly CT of the neck confirmed a left sided internal jugular thrombus. A diagnosis of Lemierre’s syndrome was suspected and four days later confirmed with a positive blood culture of Fusibacterium Necrophorum. She improved steadily with high dose iv Co-Amoxiclav, Metronidazole and anticoagulation with heparin. She was discharged home after 10 days to complete a 3 month course of oral Co-amoxiclav, metronidazole and subcutaneous heparin with 10,000 Units Tinzaparin daily. Follow up CXR and neck sonography confirmed resolution of the pneumonia and internal jugular thrombus.

Discussion In this era of modern medicine, we are encouraged to minimise the use of antibiotics for upper respiratory tract infections. However, this case illustrates the importance of being vigilant for the possibility of serious infiltrative bacterial disease when presenting in this classical clinical triad. Lemierre’s syndrome is potentially deadly but importantly a very preventable complication of bacterial pharyngitis.

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