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Introduction Lemierre\'s syndrome (LS) refers to infectious thrombophlebitis of the internal jugular vein (IJV) developed as a complication of an oropharyngeal infection. It is a serious condition which may lead to septicemia and septic embolization. LS is most frequently caused by the anaerobic Fusobacterium necrophorum. In the current post-antibiotic era, it is rare (annual incidence of 0.8 cases/million). Many clinicians are unaware of LS, leading it to be termed \'the forgotten disease.\' Signs and symptoms include odynophagia, fever and easy fatigue simulating, among others, infection by COVID-19. Broad spectrum antibiotherapy should be started promptly. If a deep abscess is present, drainage is indicated. In cases of persistent sepsis or embolization, surgical ligation/excision of the IJV may be considered. Currently, the most controversial role in LS management is anticoagulation. Compared with pre-antibiotic era mortality has much improved (0-18%). Since 2004 there are only four cases of LS reported in Portugal (Medline). Objectives To report a case of late diagnosis and highlight the pitfalls due to initial suspicion of COVID-19 infection. Materials and Methods Case report. A 37-year-old female presented to our institution with left-sided neck pain, odynophagia and fever. A diagnosis of tonsillitis was made, and the patient was discharged. COVID-19 nasopharyngeal-swab-test was negative. One week later, due to persistent fever, dyspnea, thoracalgia and easy fatigue the patient returned. Blood samples showed increased white-cell-count (17.150/μL) and C-reactive-protein (378 mg/L). On CT, areas of diffuse pulmonary infiltrates were consistent with COVID-19 infection. The patient was transferred to COVID-19 area and started ceftriaxone, azithromycin and hydroxychloroquine. On day 4, considering 3 negative tests hydroxychloroquine was abandoned. Diagnosis of an atypical pneumonia was made and antibiotherapy was changed to doxycycline and ceftazidime. Due to moderate size pleural effusion a thoracentesis was performed. On day 7, as cervical pain and tumefaction were persisting, a contrast-enhanced cervical CT was ordered, showing peritonsillar thickening and thrombosis of the left IJV with emphysema (Figure 1). Antibiotherapy was changed to Piperacillin-Tazobactam and anticoagulation was started. Results After 2 weeks, inflammatory markers were normal and a reduction in pulmonary opacities was observed. All microbiological cultures were negative. The patient completed the last 3 weeks of antibiotherapy under ambulatory hospitalization. Screening for thrombophilia was negative. Anticoagulation was kept for 3 months. Conclusions In a patient with former oropharyngeal infection presenting with pneumonia, LS should be suspected. Broad spectrum antibiotherapy should include anaerobic coverage. Anticoagulation may hasten local infection control and prevent septic embolization, optimizing pneumonia resolution.
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