Infectious Diseases 2026

Background
Lemierre's syndrome is a rare, potentially life-threatening complication of oropharyngeal infection, marked by septic thrombophlebitis of the internal jugular vein with metastatic infection, typically pulmonary. Diagnosis is challenging as it can mimic community-acquired pneumonia or pulmonary embolism. We report a case caused by Fusobacterium necrophorum and Streptococcus anginosus group, complicated by bilateral septic pulmonary emboli and cavitating nodules.

Case presentation
A 43-year-old woman presented with a 5-day history of sore throat, productive (later blood-stained) cough, fever, headache, myalgia, pleuritic chest pain, neck swelling and breathlessness. She was tachycardic and hypoxic with markedly raised CRP (427 mg/L) and D-dimer (1062 µg/L FEU). CT pulmonary angiography excluded embolism but showed bilateral consolidation and pulmonary nodules. Blood cultures grew Fusobacterium necrophorum and Strep. anginosus. Fevers persisted despite antimicrobials, prompting further investigation.

Management and outcome
Antibiotics were escalated (co-amoxiclav/clarithromycin → piperacillin–tazobactam/clarithromycin → metronidazole after culture results). Persistent pyrexia led to head and neck CT, showing bilateral tonsillitis with internal jugular and facial vein thrombophlebitis, confirming Lemierre's syndrome, plus progressive cavitating nodules (septic emboli) and a new pleural effusion. No drainable collection was found, so ENT input wasn't needed. Meropenem (increased to 2 g TDS) and clindamycin were started after multidisciplinary review; anticoagulation was given for 12 weeks. The effusion wasn't amenable to drainage. She improved, stepped down to oral amoxicillin and metronidazole for a total 4-week course, and reported full symptom resolution at follow-up, though she missed her follow-up CT.

Discussion
This case highlights the diagnostic difficulty of Lemierre's syndrome, which initially mimicked pneumonia and PE, with PE excluded on initial CTPA. Positive cultures, persistent fever and progressive cavitating nodules prompted head/neck imaging, revealing thrombophlebitis and confirming diagnosis. Pulmonary findings reflected septic embolization from the thrombosed vein. Absence of a visible abscess does not exclude the diagnosis. Management requires prolonged anaerobic-directed antimicrobials, source control where relevant, and individualised, multidisciplinary decisions on anticoagulation.

Conclusion
Lemierre's syndrome should be considered with severe oropharyngeal infection, persistent sepsis and pulmonary features like haemoptysis, cavitating nodules or septic emboli. A negative CTPA does not exclude septic pulmonary embolization. Early recognition, blood cultures, targeted imaging and multidisciplinary care are key to good outcomes.

Keywords: Lemierre's syndrome; Septic thrombophlebitis, Internal jugular vein thrombosis; Septic pulmonary emboli, Fusobacterium necrophorum; Streptococcus anginosus; antibiotics; anticoagulation; multidisciplinary approach

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