First AD

Second AD

A 20-year-old male with no medical history presents with left-sided neck pain for 5 days. Two days preceding neck symptoms, patient had a sore throat that resolved on its own. Patient reports having subjective fever one day prior to presentation. 


Extensive inflammatory change in the left parapharyngeal and carotid space. No contrast opacifies the left internal jugular vein. Hypoattenuating thrombus in the left internal jugular vein on sagittal view. Note reactive left level II/III lymph nodes.


Lemierre's syndrome is also known as post-anginal sepsis. It is a complication of a head and neck infection that results in septic thrombophlebitis of internal jugular vein, septicemia, and septic embolization. It is considered the "forgotten disease" because it has become a rare entity since the widespread use of antibiotics.


Fusobacterium necrophorum is the most common pathogen. More specifically, gram negative anaerobe that is a part of the oropharyngeal flora but can cause primary infection in otherwise healthy individuals. Infection of parapharyngeal space occurs through direct spread from oropharynx, lymphatic, or venous through tonsils. IJV thrombus may lead to septic emboli, most commonly to lungs.


Acute pharyngitis followed three to 10 days by fever, rigrs, malaise (onset of septicemia). IJV thrombus causes pain, tenderness, swelling, and trismus. Hoarseness and dysphagia can occur if cranial nerves are involved.


Ultrasound neck or contrast-enhanced CT for IJV thrombus. CT chest for septic emboli; chest radiographs may not be sensitive.


Intravenous antibiotics with good anerobic coverus. There is no clear consensus on anticoagulation.


This patient was admitted to medicine and started on broad-spectrum IV antibiotics. The patient remained afebrile. Blood cultures were negative for growth, although they were drawn after the first dose of antibiotics. The patient was discharged after three days and continued IV antibiotics (via PICC) for two weeks.

One month following admission, the patient was re-evaluated with a follow-up CT neck, which showed resolution of initial findings and minimal residual stranding in the left neck.


1. Screaton NJ, Ravenel JG, Lehner PJ, et al.  Lemierre syndrome: forgotten but not extinct – report of four cases. 

2. Pinheiro PE, Miotto PD, Shigematsu NQ, Tamashiro E, Valera FC, Anselmo-Lima WT. Lemierre’s syndrome: a pharyngotonsillitis complication. 

3. Davidoss N, Ha JF, Anderson JR, Rodrigues S. Lemierre’s syndrome – an unusual complication of otitis externa in a young, healthy female.

20-year-old male with no medical history presents with left-sided neck pain for 5 days. 

Image IQ: 20-year-old Male, Left Neck Pain

Hailey Choi, MD

Erini Makariou, MD