Lemierre's syndrome with cavernous sinus thrombosis: A therapeutic dilemma

Introduction: Internal jugular vein septic thrombophlebitis, known as Lemierre's syndrome, is an uncommon complication of deep-space head and neck infections. Cavernous sinus thrombosis is another potential complication of head and neck infections. A clinical picture of these in combination is exceedingly rare. Here is a case of Lemierre's syndrome with complicating cavernous sinus thrombosis caused by a deep-space neck infection. Method: A 21-year-old, previously healthy man presented to the emergency department for right facial swelling and bilateral pleuritic chest pain. A SARS-CoV-2 polymerase chain reaction nasopharyngeal swab, taken in the setting of upper respiratory infection symptoms, was negative 5 days prior. He was admitted to the intensive care unit (ICU) for medical management of facial cellulitis complicated by internal jugular vein thrombosis, mediastinitis, septic pulmonary emboli, and cavernous sinus thrombosis. Results: Therapeutic anticoagulation and culture-directed therapy to Fusobacterium necrophorum were started. He developed pleural effusions attributed to pulmonary septic emboli requiring chest tubes and he developed a large subcapsular hepatic hematoma necessitating embolization. Throughout his course, he did not develop cranial nerve palsies consistent with cavernous sinus thrombosis syndrome, despite progressive imaging findings. After 2 weeks in the ICU, he was stabilized and then managed with long-term therapy. Conclusion: This case demonstrates the challenges of treating 2 rare complications of deep-space neck infections in a patient with no identifiable site for surgical source control. The role of anticoagulation in Lemierre's syndrome and cavernous sinus thrombosis is controversial and not without great risk. The complications that can arise from both the disease process and treatment must be weighed in each case.