Lemierre Syndrome Without Pharyngitis: An Atypical Case Posing a Diagnostic Challenge

Atypical presentations of Lemierre syndrome can delay diagnosis, particularly in patients without preceding oropharyngeal symptoms.We present a case of a 61-year-old woman with poor dentition who presented with confusion, lethargy, headache, and hyponatremia without antecedent pharyngitis.Blood cultures grew Streptococcus constellatus, and cerebrospinal fluid (CSF) analysis demonstrated neutrophilic pleocytosis and elevated protein.Persistent severe headaches, high fever, right eye pain, decreased right distant visual acuity, and photophobia prompted venous imaging, which revealed a near-occlusive thrombus of the proximal left internal jugular vein with extension into the dural venous sinuses.Chest computed tomography (CT) demonstrated a moderate-to-large left pleural effusion.Treatment included intravenous ceftriaxone, metronidazole, therapeutic anticoagulation, chest tube placement, and intrapleural fibrinolytic therapy.Her neurologic status returned to baseline, and she was discharged after a 20-day hospitalization to complete antimicrobial and anticoagulation therapy.This case highlights the importance of considering Lemierre syndrome in older patients with unexplained bacteremia and neurologic or pulmonary findings, even in the absence of classic oropharyngeal symptoms.