Lemierre's Syndrome: An Unlikely Diagnosis in a Patient Presenting with Diarrhoea and Vomiting, or Maybe not?

Lemierre's syndrome is an infectious thrombophlebitis of the internal jugular vein (IJV) where the commonest causative agent is a Fusobacterium from a tonsillar or peritonsillar abscess. This is a case presentation of a patient whose primary complaint was diarrhoea. The blood cultures of this patient grew a Fusobacterium necrophorum which prompted imaging. The imaging demonstrated a right peritonsillar abscess and IJV thrombosis with septic emboli in the lungs. Key points highlighted are: 1) blood cultures remain a key investigation in making a diagnosis in the septic patient; 2) abdominal symptoms can be part of Lemierre's syndrome; 3) abdominal symptoms (abdominal pain, vomiting and diarrhoea) have been characterised as the third, fourth and fifth most common feature after fever and dyspnoea. This case is presented because it shows how Lemierre's syndrome can present with abdominal features, and this may be incongruent with clinicians' understanding and teaching.

Learning points: Lemierre's syndrome is an infectious thrombophlebitis of the internal jugular vein most commonly due to Fusobacterium necrophorum originating from a tonsillar or peritonsillar abscess, which may cause septic emboli in the lungs.Gastrointestinal symptoms, including diarrhoea, are commoner than appreciated or classically taught in this syndrome.Blood cultures are a key investigation in the septic patient and in those that grow a Gram-negative rod, Fusobacterium should be considered, and suspicions of Lemierre's syndrome should be raised.