Early Radiographic Warning Signs of Impending Lemierre's Syndrome

Lemierre's syndrome is a rare and potentially life-threatening complication of head and neck infections, such as bacterial pharyngitis or tonsillitis. It is characterized by the extension of infection into the lateral pharyngeal spaces, leading to subsequent septic thrombophlebitis of the internal jugular vein(s). Although relatively uncommon since the advent of appropriate antibiotic therapy, the incidence of Lemierre's syndrome has increased in the past 15 years, especially among young, healthy adults. This increase is likely attributed to the increasing prevalence of oropharyngeal infections in this population, making an initial diagnosis of Lemierre's syndrome often elusive on presentation. Delayed recognition of this syndrome can result in treatment delays, increasing the morbidity and mortality in this condition. The diagnosis of Lemierre's syndrome is typically confirmed through the identification of thrombophlebitis of the internal jugular vein on radiographic imaging and the isolation of anaerobic bacteria in blood cultures. Treatment involves prolonged antibiotic therapy and, often, anticoagulation. This case report presents a rare complication of bacterial tonsillitis, with initial imaging that demonstrated left peritonsillar phlegmon and subtle micro-occlusions of the left internal jugular vein on early imaging. Within four days, the infection rapidly progressed to complete occlusion of the internal jugular vein with pulmonary septic emboli, culminating in Lemierre's syndrome. This case highlights the importance of early detection and treatment of subtle radiographic findings of thromboses, along with consideration of social determinants of health, in the setting of head and neck infections to avoid rapid progression to Lemierre's syndrome, a disease with an elusive initial presentation and potentially fatal outcomes.