Thrombophlebitis of the external jugular vein: A variant of Lemierre’s syndrome

Abstract

A previously healthy 41-year-old woman presented with a 4day history of right mandibular pain, toothache, and trismus, followed by fever and chills. Her fever was recorded at 41.0°C. Physical examination revealed swelling and redness that extended from the patient’s right cheek to the lower area of her jaw, with inability to open her mouth by one cm. Contrast-enhanced computed tomography showed abscesses in the root of the right mandibular second molar and right parapharyngeal and submandibular space (Figs. 1 and 2), right external jugular vein (EJV) thrombosis (Fig. 1), and septic pulmonary emboli (Fig. 3). She underwent extraction of the right mandibular second molar, aspiration of thrombus in the right EJV, and surgical drainage of the abscesses. Cultures of blood and the EJV thrombus were positive for alpha-hemolytic Streptococcus, thereby leading to a diagnosis of right EJV thrombophlebitis. Ampicillin sulbactam was administered for four weeks, and the patient was discharged without complications. A combination of thrombophlebitis of the internal jugular vein (IJV) and septic emboli is classically termed Lemierre’s syndrome (LS), which is rare and caused by an anaerobic organism following an oropharyngeal infection [1]. Thrombophlebitis may be caused by bloodstream infection, while direct invasion from soft tissue infection or spread via the lymphatic pathway is also anticipated [2]. Although rare, several variants of LS with thrombophlebitis of the facial vein, subclavian vein, cavernous sinus, sigmoid sinus, and EJV have been reported. The involvement of the EJV is anatomically