A50-24 Lemierre Syndrome Precipitated by Peritonsillar Abscess in the Setting of Subacute Epstein-Barr Virus Infection: A Case Report

Abstract Introduction Lemierre’s syndrome is characterized by an oropharyngeal infection that progresses to septic thrombophlebitis of the internal jugular (IJ) vein with metastatic septic emboli, most commonly due to Fusobacterium necrophorum. Although uncommon, its incidence appears to be increasing, particularly in adolescents and young adults. EBV-related tonsillitis may predispose to anaerobic invasion. Delay in diagnosis can lead to significant morbidity from sepsis, pulmonary embolic phenomena, and multisystem organ dysfunction. This report describes a young adult with subacute EBV infection who developed F. necrophorum bacteremia arising from a peritonsillar abscess, complicated by severe sepsis and pancreatitis. Case description A 24-year-old male with no medical history developed a sore throat. Two days later, he woke early in the morning and collapsed to the floor with agonal respirations. Emergency medical services were contacted and the patient was transported to the emergency department where he was intubated for airway protection. Initial workup revealed high fever, severe sepsis, bilateral pulmonary nodules, and acute pancreatitis. Infectious workup revealed subacute Epstein Barr Virus (EBV) infection. On day three of hospitalization, the patient was extubated without complication. On day four, blood cultures yielded F. necrophorum.. The patient’s voice became increasingly muffled and he developed unilateral erythema of the neck. A computed tomography (CT) scan of the neck revealed peritonsillar abscess (Figure 1). An ear-nose-throat specialist was consulted who recommended a course of dexamethasone and no surgical intervention. The patient’s condition continued to improve with ampicillin-sulbactam, levofloxacin, steroids, and fluid resuscitation, and he was discharged home on hospital day eight. Discussion F. necrophorum is a gram-negative anaerobe that colonizes the oropharynx and is the primary pathogen implicated in Lemierre’s syndrome. The classic sequence begins with tonsillopharyngitis, followed by peritonsillar/parapharyngeal extension, septic thrombophlebitis of the IJ vein, and septic emboli. EBV infection has been associated with increased risk of F. necrophorum superinfection. Mechanistically, EBV-mediated lymphoid hyperplasia, mucosal ulceration, and tissue hypoxia may facilitate anaerobic invasion and abscess formation. Clinically, co-infection can obscure diagnosis when early symptoms are attributed solely to mononucleosis. In this case, the timing of subacute EBV serologies, progressive unilateral neck findings, muffled voice, and bacteremia underscored the need for dedicated neck imaging. Conclusions Lemierre’s syndrome should be considered in young adults with severe pharyngitis, unilateral neck findings, and signs of sepsis—especially when EBV infection is present. F. necrophorum bacteremia with a peritonsillar abscess can be managed successfully with prompt, targeted anaerobic coverage and careful airway assessment. This abstract is funded by: None