Clinical practice mostly involves treating fairly common ailments, so when a patient presents
with common symptoms, it can be challenging to recognize the point where common becomes uncommon.
The following true story is a case in point.
A 20-year-old college student visits her pediatrician after 3 days of throat pain,
malaise, cough, and chills. Her vital signs are normal. The doctor notes tender enlarged lymph
nodes in her neck, a red throat, and swollen tonsils. A rapid strep test is negative. The
doctor performs a throat culture and advises her to drink fluids and take ibuprofen as needed.
Most physicians would probably suspect viral pharyngitis,
which usually manifests as a low-grade fever, a cough, and congestion. This was pre-Covid-19.
The patient comes back the next day with worsening throat pain and difficulty
swallowing. Her voice sounds muffled, though she can speak comfortably.
A muffled "hot potato" voice suggests upper airway obstruction. Asymmetric tonsillar enlargement may
also indicate an abscess or infection. Let's review the patient's other symptoms and history.
The patient has no fever, and her vital signs are normal, but her tonsils and lymph nodes are still
enlarged. She says her roommate recently had an upper respiratory infection. The patient isn't
taking any long-term medications. She once had MRSA cellulitis, and as a child, she underwent
a left carotid body resection for a benign tumor. She's had all her routine vaccinations.
The patient could still have a strep infection despite the negative test, so the physician
obtains a complete blood count and a test for mononucleosis, which also comes back negative.
One dose of oral dexamethasone is prescribed, with acetaminophen as needed. Glucocorticoids
like dexamethasone might be useful in some cases of sore throat, but are not generally recommended,
as they may transiently reduce symptoms, but are associated with side effects. They
may decrease host-pathogen immune response and they do not treat the underlying cause.
The next day, the strep culture comes back negative. Serologic testing for Epstein—Barr
virus IgG antibody to early IgG antigen is also negative, but EBV IgG and IgM and EBV IgG
antibody nuclear antigen are positive. The results suggest that the patient likely had mono recently, but
EBV serologies can be challenging to interpret. The results are more suggestive of a recent past
infection than an acute one. One day later, the patient visits the ED with worsening throat pain,
a still-muffled voice, pain on swallowing, and shortness of breath. She is not in any obvious
distress, though her heart rate is faster than normal. Her tonsils are still enlarged. She has
painful swollen lymph nodes in her neck but no limitation in neck movement. A liter of IV fluid
brings her heart rate down. Blood work reveals a slightly decreased platelet count. Benzocaine
spray is administered for her sore throat, along with another liter of IV fluid, and she is sent
home as soon as she can swallow liquids. These findings are concerning. The elevated heart rate
and decreased platelet count are alarm signs. At this point, further diagnostic evaluation
and close observation are recommended. Three days later, the patient is back in the ED.
She can't clear the secretions pooling in her respiratory tract and has a worsening cough,
ongoing throat pain, and foul-smelling breath. She also reports three episodes of vomiting,
and she is anxious and appears critically ill. She has a fever and her heart rate and respirations
are rapid. She notes pain on the left side of her neck when she turns her head to the right. Her
throat appears swollen. These symptoms are concerning for upper airway obstruction — a
life-threatening emergency. Without urgent intervention, airway compromise could progress,
and she may need to be intubated or even require an emergency tracheostomy.
Further blood work reveals a slightly elevated white-cell count, anemia, a low platelet count,
signs of evolving kidney dysfunction, and metabolic acidosis. These findings
are worrisome. She might be developing septic shock — another life-threatening emergency.
The patient is given 1000 mg of acetaminophen. Over the next 2 hours, she becomes increasingly
agitated, her temperature rises to dangerous levels, her heart rate increases, and her blood
pressure falls. Her oxygen saturation is 97%. IV fluid briefly raises her blood pressure, but
it soon drops again. She is given more IV fluid and IV ceftriaxone, a broad-spectrum antibiotic.
Her lactate level suggests that her organs are not getting sufficient blood supply. A chest x-ray
reveals abnormalities in the lungs consistent with fluid or solid material — most likely infection.
Contrast-enhanced CT of the neck shows findings consistent with pus next to the tonsil and a blood
clot in a left lingual vein at its juncture with the internal jugular vein. The patient is given
broad-spectrum antibiotics. The patient has an infected blood clot in her internal jugular vein,
or Lemierre's syndrome. This is a rare condition often preceded by bacterial pharyngitis and dental
infections, though this patient did not have evidence of either. Less commonly, it may be
triggered by infectious mononucleosis. Variants of Lemierre's syndrome can affect any of the large
venous structures of the face, and infection can spread to the surrounding facial structures.
High-grade fever, neck pain, and respiratory distress are typical presenting symptoms of this
syndrome, which can also lead to infected blood clots obstructing a blood vessel,
infiltrates in the lungs, lung abscess, sepsis, septic arthritis, and even bone infection.
The patient is transferred to the ICU and put on supplementary oxygen. She begins to breathe
comfortably, though her heart rate remains rapid and her blood oxygenation level below normal.
She is given three new antibiotics. Nasopharyngeal endoscopy reveals a
fullness of the tonsils that's greater on the left than the right, and dexamethasone
is administered. CT angiography reveals seeding of bacteria to the lungs. There are also small
pockets of air in the right clavicle. On the patient's second day in the ICU,
anaerobic cultures grow gram-negative bacilli, and she has pain in her right clavicle.
Many bacterial agents can cause Lemierre's disease, including MRSA and Pseudomonas
aeruginosa. Here, the gram-negative rods are most likely F. necrophorum,
which produces hydrogen sulfide gas and is a known cause of emphysematous osteomyelitis.
The antibiotic regimen is narrowed, and damaged tissue is surgically removed to control the source
of infection. Results of blood cultures confirm F. necrophorum. The patient's pain abates after
surgery, and she's discharged after 8 days, but antibiotic treatment continues for 12 more weeks.
One-month post-op the patient still has clavicular pain, but she has otherwise recovered.
The patient's swollen glands and sore throat were presumed to be caused by mono, but the serology
results didn't show acute mononucleosis. She presented several times with worsening symptoms
before additional diagnostic evaluation was performed, resulting in a delayed diagnosis.
Unfortunately, in the interim, she had substantial clinical deterioration
and experienced complications. Common symptoms usually indicate a common problem,
but we need to have an early index of suspicion for a more serious condition when "typical" cases
evolve atypically. Fortunately, the vast majority of sore throats are not serious.