A burning throat, intense neck tenderness
She closed her calculus textbook and put it aside. The text and equations on the page had started to blur together, and all she could focus on was how her throat was on fire.
She closed her calculus textbook and put it aside. The text and equations on the page had started to blur together, and all she could focus on was how her throat was on fire.
She took a few small sips from the bottle of orange juice that had been her constant companion for the last week. "It can't be the flu," she thought, since she didn't have a headache, runny nose, cough, or muscle aches.
Having had strep throat many times as a child, she had initially thought this episode was no different. However, she had already gone to the university health clinic and had tested negative for strep throat. The nurse had diagnosed her as having a viral infection and recommended rest and lots of fluids.
She glanced at herself in the mirror and was surprised to find herself looking flushed. She had no major health issues, and usually two weeks into an illness like this she should be recovering, not getting progressively worse.
The phone rang and she answered it. "Hello? Oh, hi, Mom," she started to say, but her mother cut her off.
"What is wrong with your voice?" she asked, alarmed by the raspy voice greeting her.
"I just have a sore throat that won't go away. . . . ouch, it even hurts to open my mouth," the 21-year-old daughter replied. "And I think I might have a fever today."
The mother was concerned to learn about her symptoms. Since it was late evening, she asked her daughter to go to the local emergency room and said she would arrive there shortly herself.
In the emergency room, the young woman's vital signs were notable only for a temperature of 103 degrees Fahrenheit. Although the woman denied any lightheadedness, her blood pressure was low-normal, and she was started on intravenous fluids.
The physician evaluated the woman and noted significant swelling of her tonsils with visible pus. She also had exquisite tenderness with palpation along the left side of her neck, and was visibly uncomfortable with opening and closing her mouth. Given her symptoms, the physician suspected the woman had not been able to take in sufficient fluids or food.
The ER team had blood drawn for laboratory tests and sent the young woman for a CT scan of her neck. She was admitted to the hospital for further management. Her labs showed an elevated white blood cell count, which is often a sign of infection, and a high creatinine level, consistent with dehydration.
When the admitting physician received the CT results, she had the diagnosis in hand and reached for her phone to contact a consultant who could help her manage this condition.
What did this young woman have? What treatment would she need?
Solution:
The woman's CT scan results showed that there was swelling of her tonsils with pus extending all the way to the neck veins on the left side.
The radiologist also saw a clot in the left large internal jugular vein. The infection had spread to the vein, causing thrombophlebitis, a clotted and infected blood vessel.
This is Lemierre's syndrome, the physician thought. The disease was described by French physician Andre Lemierre in the mid-1930s. A blood clot, laden with bacteria, typically lodges in the jugular vein close to the tonsils. It can on occasion be deadly when bits of the infected clot break off and spread to the lungs or other areas of the body.
The patient was started on intravenous antibiotics and had the tonsillar abscess lanced and drained by the ear, nose and throat doctors.
Over the next two days, her fevers resolved and she noted substantial improvement in her throat and neck pain. She was able to open her mouth more fully, and her appetite improved.
The fever, sore throat, and progressive neck pain all were worrisome for Lemierre's syndrome. The bacterium typically responsible (a bug called fusobacterium) causes the infected thrombophlebitis of the jugular vein usually within a week of the sore throat. The bug can spill into the bloodstream and is often detected with blood cultures. Lemierre's syndrome is most commonly seen in healthy young adults.
Once the young woman was able to eat and drink without intolerable pain, she was discharged home. After all, she still had some calculus homework to tackle.