An Unusual Cause of Sore Throat and Neck Swelling

Original article

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IMAGE CHALLENGE An unusual cause of sore throat and neck swelling

CLINICAL INTRODUCTION A 61-year-old man presented with swelling of the neck. He had experienced coughing, fever and sore throat for the previous few days and had been started on antibiotic treatment by his general practitioner. He presented to the emergency department because the symptoms failed to subside and he developed swelling of his neck. On examination, he was afebrile, and a hard, 9×4 cm in size, mobile mass with no redness was observed on the right side of his neck (ﬁgure 1).

QUESTION What is your diagnosis? A. Pneumonia B. Tuberculosis C. Q fever D. Lemierre’s syndrome E. Mononucleosis Figure 1 Anterior view of the patient’s neck. For the answer see page 646

Bowness J, et al. Emerg Med J 2015;32:620–625. doi:10.1136/emermed-2014-203689 625 Prehospital care

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IMAGE CHALLENGE An unusual cause of sore throat and neck swelling

From the question on page 625 ANSWER: D Lemierre’s syndrome (LS). LS is also known as anaerobic postan- ginal septicaemia. The primary site of infection is the palatine tonsils and peritonsillar tissue. Other, rarer, locations of infection are the lung, middle ear, mastoid, teeth and sinuses. Local invasion and septic thrombophlebitis of the internal jugular vein are seen after primary infection.1 The two most commonly iso- lated disease agents are Fusobacterium necrophorum and Klebsiella pneumoniae. The disease most commonly manifests Figure 3 CT of the patient’s neck shows thrombosis of the internal with sore throat, fever, chills, shivering and unilateral neck pain jugular vein (axial section). White arrows show the thrombosis in the and swelling in young, healthy individuals. The diagnosis of LS right jugular vein lumen, black arrows show oedema around is made by Doppler ultrasound or contrast CT and blood sternoclavicular muscle and bilateral lymphadenopathy. culture in addition to clinical suspicion.2 LS is treated with anti- biotics effective against anaerobes and Gram-negative bacteria. Suleyman Turedi, Suha Turkmen, Metin Yadigaroglu Anticoagulants can be used in treatment if the clinician so 3 Department of Emergency Medicine, Faculty of Medicine, Karadeniz Technical wishes. Mean length of treatment is 2–6 weeks. University, Trabzon, Turkey In order to determine the origin of swelling in our patient, Correspondence to Dr Suha Turkmen, Department of Emergency Medicine, School ultrasonography of the neck was performed. There was throm- of Medicine, Karadeniz Technical University, Trabzon 61080, Turkey; bosis which almost filled the right jugular vein lumen (figure 2). [email protected] CT of the neck demonstrated thrombosis in the right jugular vein lumen, oedema around sternoclavicular muscle and bilat- Contributors All authors took an equally active part in this article. ST is the first eral lymphadenopathy (figure 3). author and planned the article. MY assessed the patient in the ED. ST helped MY for the further management of the patient. MY helped ST and ST in writing the manuscript. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; internally peer reviewed.

To cite Turedi S, Turkmen S, Yadigaroglu M. Emerg Med J 2015;32:646. Accepted 8 March 2015 Emerg Med J 2015;32:646. doi:10.1136/emermed-2015-204645

REFERENCES 1 Eilbert W, Singla N. Lemierre’s syndrome. Int J Emerg Med 2013;6:40. 2 Turan A, Cam H, Dadali Y, et al. A case of lemierre syndrome secondary to otitis Figure 2 A linear array transducer (frequency 7.5 MHz) was used with media and mastoiditis. Case Rep Emerg Med 2014;2014:208960. short access (transverse) with indicator towards left. Ultrasound (USG) of 3 Phua CK, Chadachan VM, Acharya R. Lemierre Syndrome—Should We Anticoagulate? – the patient’s neck shows thrombosis of the internal jugular vein. A Case Report and Review of the Literature. Int J Angiol 2013;22:137 42.

646 Wimalasena YH, et al. Emerg Med J 2015;32:642–646. doi:10.1136/emermed-2013-202928