A Variant Case of Lemierre's Syndrome Caused by Streptococcus intermedius Presenting as Unilateral Eyelid Swelling

A 14-year-old female presented with a 1-week history of left upper eyelid erythema and ptosis (Figure 1a). She reported odontalgia 2 weeks prior. Initial diagnosis of preseptal cellulitis was made, but empiric treatment with oral azithromycin followed by intravenous clindamycin failed. The patient developed fever, and the swelling significantly expanded with worsening tenderness (Figure 1b). Blood cultures were negative. Given the clinical deterioration, bedside ultrasound was performed. It revealed multiple periorbital abscesses and, crucially, thrombosis in the left facial vein extending to the external jugular vein, indicating septic thrombophlebitis (Figure 1c). No internal jugular vein involvement was detected. Drainage yielded bloody, purulent fluid. Next generation sequencing and culture of the drainage identified Streptococcus intermedius, a pathogen known for abscess formation 1. (Susceptibility profile in Table S1). The patient was diagnosed with a variant of Lemierre's syndrome (LS). While classic LS involves the internal jugular vein, infection in the face can spread via the valveless facial veins 2. The patient denied any hypercoagulable comorbidities. Management was complicated by the patient's beta-lactam allergy. She was initially treated with vancomycin, meropenem, and metronidazole. Upon confirmation of the pathogen, meropenem was discontinued. Vancomycin was chosen due to the patient's age (precluding fluoroquinolones) and allergy profile, while metronidazole covered potential odontogenic anaerobes. She continued with intravenous vancomycin and metronidazole, followed by oral linezolid. Anticoagulation therapy was withheld due to the absence of intracranial extension or pulmonary embolism. At the 1-month follow-up, the thrombus had absorbed, and symptoms resolved (Figure 1d). This case serves as a visual alert for Dermatologists. Persistent eyelid swelling after dental infection, especially when resistant to antibiotics, should prompt sonographic evaluation for facial vein thrombosis. Early utilization of ultrasound can be lifesaving. Conservative management without anticoagulation can be effective in non-progressive cases 3. This work was supported by the National Natural Science Foundation of China (82430100). Informed consent has been obtained from the patient and her parents for the use of her medical records and imaging data for educational purposes. The authors declared no conflicts of interest. All data are incorporated into the article. Table S1: Antimicrobial susceptibility profile of Streptococcus intermedius isolated from abscess drainage. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.