A 20-year-old Chinese female with good past health presented to the emergency department in October 2014 with a few days history of fever, dizziness, and headache. She was hypotensive upon presentation with blood pressure of 73/48 mm Hg and pulse rate of 90 beats/min but responded to fluid resuscitation. Physical examination revealed no other significant findings. Her white cell count was 4.4 x 10⁹ /L on admission but increased to 13.4 x 10⁹ five days later. Neutrophil predominance was observed. Subsequent gradual decline and normalisation of the white cell count was noted after initiation of intravenous antibiotics.

Computed tomographic (CT) abdomen and pelvis was initially requested based on the clinical suspicion of intra-abdominal sepsis or gynaecological pathologies but yielded no remarkable findings. Chest X-ray (CXR) was also performed for preliminary assessment and was initially unremarkable. Follow-up serial CXRs, however, showed an increasing number of cavitary lesions in both lungs with no zonal predominance (Fig 1).

Non-contrast CT thorax was deemed necessary for further characterisation of these lesions and confirmed multiple cavitary lesions of variable sizes involving all the lung lobes (Fig 2). Thick irregular walls with fluid content and perifocal consolidative changes were noted in some of these lesions, which are compatible with an infective process. Further imaging workup was then arranged to identify any potential source of the septic emboli but echocardiogram did not reveal any heart valve vegetation.

On further questioning, the patient reported mild left neck pain. Doppler ultrasound of the neck was then performed based on the clinical suspicion of Lemierre’s syndrome. A markedly narrowed lumen with thickened wall and dampened flow signal was noted across the left internal jugular vein suspicious of venous thrombosis (Fig 3). This was subsequently confirmed on contrast CT neck and thorax (Fig 4).

Mycoplasma-Fusobacterium polymerase chain reaction study confirmed the causative organism as Fusobacterium necrophorum, which is the classic bacteria described in Lemierre’s syndrome.

The patient was promptly treated with intravenous antibiotics and anticoagulant. Her clinical condition gradually improved and follow-up CT scan demonstrated interval resolution of the cavitary lung lesions. She was subsequently discharged with oral antibiotics and anticoagulants.

Lemierre’s syndrome remains a rare yet potentially life-threatening disease especially in young adults.1 A high index of clinical suspicion is therefore imperative to ensure prompt and timely imaging investigations that are integral to its diagnosis. Unrecognised and untreated systemic dissemination can result in a poor prognosis.2 Contrast-enhanced CT played a pivotal role in terms of evaluation of the pulmonary sepsis and assessment of the jugular vein thrombosis in this patient.3

1. Shook J, Trigger C. Lemierre’s Syndrome. West J Emerg Med 2014;15:125-6. Crossref

2. Lai C, Vummidi DR. Images in clinical medicine. Lemierre’s Syndrome. N Engl J Med 2004;350:e14. Crossref

3. Screaton NJ, Ravenel JG, Lehner PJ, Heitzman ER, Flower CD. Lemierre syndrome: forgotten but not extinct—report of four cases. Radiology 1999;213:369-74. Crossref