Presentation
10 days of sore throat. Presented with left neck swelling and difficulty swallowing. Difficulty turning head. Left basal crackles. Septic with neutrophilia and CRP >300.
Patient Data
Inflammatory swelling and stranding involving the left palatine tonsil and posterior pharyngeal wall, extending beyond the pharyngeal mucosal space to involve the parapharnygeal fat and submandibular space tissues. The SMG is swollen and there is fat reticulation in the submandibular space with thickening of the platysma. No frank collection is currently demonstrated. Non-encapsulated fluid is noted in the retropharyngeal space, although there is no extension into the mediastinal tissues.
Enlarged left IB / II / III nodes are considered reactive with no concerning features.
Non-occlusive thrombus in the adjacent left internal jugular vein. The visualized intracranial dural sinuses are normal, and the rest of the major head and neck vessels are patent.
In the partially imaged chest there are several subpleural mixed solid / ground-glass foci which in this context are suspicious for septic emboli. No large vessel PE evident.
Case Discussion
This presentation with these appearances are characteristic for Lemierre syndrome with a diffuse neck infection (with or without frank collection), venous thrombophlebitis and evidence of distant organ involvement - in this case suspected septic pulmonary emboli. These developed into maturing lesions on later chest imaging.
Initial blood cultures confirmed a Gram negative septicemia with Fusobacterium necrophorum, the classically described organism in Lemierre syndrome.