neck swelling

A 50-year-old male with insulin-dependent Type 2 Diabetes presented to the emergency department with three days of pain and swelling on the right side of his neck. He endorsed progression of his symptoms, reporting that he was now having fevers, myalgias, and intermittent difficulty swallowing solid foods.

 

Vitals: BP 153/96; HR 110; T 100.0°F; RR 16; O2 sat 97%

General: Appears uncomfortable

HEENT: Mild right-sided facial swelling. No trismus. No gingival inflammation or swelling or induration to suggest abscess. There is focal swelling and tenderness to palpation, without overlying erythema, throughout the right submandibular triangle, and along the sternocleidomastoid.

MSK: Limited active right shoulder range of motion secondary to pain

WBC: 10.4

Hgb: 14.4

Plts: 213

Na: 131

K: 3.7

A1C: 13

Lemierre syndrome (LS) is a rare complication of bacterial pharyngitis/tonsillitis and involves an extension of the infection into the lateral pharyngeal spaces of the neck with subsequent septic thrombophlebitis of the internal jugular vein (as seen on CT). Patients may present with trismus, dysphagia, and fever. Due to the possibility of widespread septic emboli, patients may experience sequelae of systemic infection with dyspnea, focal neurologic deficits, and abdominal pain. Treatment consists of prompt antibiosis and rapid source control.

Most cases of bacteremia in Lemierre syndrome are caused by Fusobacterium necrophorum, an anaerobic gram-negative rod that colonizes the oropharynx. This bacterium causes platelet aggregation and thrombus formation through hemagglutinin production and direct activation of the coagulation cascade. However, up to one-third of patients are found to have a polymicrobial infection with streptococcus and staphylococcus species frequently present.

Take-Home Points

  • Lemierre syndrome (LS) is a rare infection. However, the incidence of LS has been increasing in recent decades due to more judicious use of antibiotics for pharyngitis.
  • A high index of suspicion must be maintained to diagnose Lemierre syndrome, with special attention to alternative diagnoses such as Ludwig angina, retropharyngeal abscess, or meningitis.
  • A thorough investigation of associated symptoms is imperative as these may represent sequelae of septic emboli.

  • Foo EC, Tanti M, Cliffe H, Randall M. Lemierre’s syndrome. Pract Neurol. 2021 Oct;21(5):442-444. doi: 10.1136/practneurol-2021-002928. Epub 2021 May 7. PMID: 33963085.
  • Forrester LJ, Campbell BJ, Berg JN, Barrett JT. Aggregation of platelets by Fusobacterium necrophorum. J Clin Microbiol. 1985 Aug;22(2):245-9. doi: 10.1128/jcm.22.2.245-249.1985. PMID: 4031037; PMCID: PMC268368.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

Alejandro Avina-Cadena, MD, MPH

Alejandro Avina-Cadena, MD, MPH

Resident Physician
Boston Medical Center
Alejandro Avina-Cadena, MD, MPH

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