October 2025

Lemierre's Syndrome: enhancing early diagnosis and management through thoracic imaging

Dr Raeesa Patel, Dr Rachelle Rachmat, Dr Philip Touska, Dr Giulia Benedetti

Background

Lemierre’s syndrome is a rare but important complication of bacterial pharyngitis or tonsillitis in otherwise healthy, young individuals, characterised by septic thrombophlebitis of the internal jugular vein (IJV). The inflamed and thrombosed IJV may shower emboli into the systemic circulation, which most commonly deposit in the lungs (1). Cross-sectional imaging plays a crucial role in early diagnosis by identifying IJV thrombosis and associated septic emboli.

Case study

29 year old female patient presented to the emergency department with fever, sore throat and neck swelling. A flexible nasal endoscopy (FNE) by the ENT team demonstrated left lateral hypopharyngeal wall swelling which is in keeping with tonsillitis. She was treated with intravenous antibiotics and fluids. Despite antibiotics, inflammatory markers continued to rise. Therefore, a CT neck and thorax were performed (figures 1-3). The main findings were described as:

“Left superior peritonsillar space collection with ipsilateral thrombophlebitis involving the IJV. Associated with multiple pulmonary infiltrates compatible with septic emboli.”

The collection was aspirated, and antibiotics were amended. The patient clinically improved and was discharged with an outpatient antibiotic regime. 

Imaging findings

A close-up of a scan of a human body AI-generated content may be incorrect.A close-up of a scan of a person's face AI-generated content may be incorrect.

Figure 1 - Axial and coronal contrast-enhanced CT neck. A 1.9 cm collection within the left superior peritonsillar space.

 

A close-up of a ct scan AI-generated content may be incorrect.

Figure 2 - Axial contrast-enhanced CT neck. The left internal jugular vein is thrombosed, peripherally enhances and is associated with perivascular stranding suggestive of thrombophlebitis

A close-up of a chest x-ray AI-generated content may be incorrect.

A close-up of a chest x-ray AI-generated content may be incorrect.

Figure 3 -Axial CT thorax.  Multiple peripheral foci of nodular consolidation with some surrounding ground glass opacification. The largest measured 20mm within the right lower lobe. Findings are compatible with septic emboli. 

Discussion

Lemierre’s syndrome can be an elusive diagnosis, highlighted by this case where the patient did not exhibit respiratory symptoms and had a normal admission chest radiograph. The most common causative organism is Fusobacterium necrophorum (1), however 10% of cases have negative blood cultures, as in this case (2). A low threshold for thoracic imaging should be reserved in patients with atypical symptoms or increasing severity despite standard therapy. 

Learning points

  1. Lemierre’s syndrome should be suspected in young patients with pharyngitis/ tonsilitis when the clinical picture is out of keeping with examination findings.
  2. Cross-sectional imaging of the head and neck is crucial in the early diagnosis and management of Lemierre's syndrome. 

References

  1. Allen BW, Anjum F, Bentley TP. Lemierre syndrome. InStatPearls [Internet] 2023 Jul 31. StatPearlsPublishing.

  2. Righini CA, Karkas A, Tourniaire R, N'Gouan JM, Schmerber S, Reyt E, Atallah I. Lemierre syndrome: study of 11 cases and literature review. Head & neck. 2014 Jul;36(7):1044-51.