Medical Case: Recurrent tonsillitis - What's behind it?

A young man shows up at emergency with purulent tonsillitis. The examination leads to four suspected diagnoses. Which one would you support?

A young man with sore throat, and an unusual diagnosis

The seventeen-year-old male attends the emergency room with shortness of breath, fever and difficulty swallowing. The illness started with sore throat and rhinitis a fortnight ago and initially improved before worsening again on the day of entry to the ward.

The clinical examination revealed a purulent tonsillitis as well as redness and swelling of the neck - both on the left side. The laboratory examination revealed a leucocytosis and an elevated CRP value.

Further diagnostic measures: a chest X-ray to clarify the shortness of breath cause, a CT scan, and a sonography of the neck. In addition, blood cultures are preserved.

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Sonographically, a thrombosis of the internal jugular vein (IJV) is found on the left side. The X-ray shows a cave in the left upper lobe, and the computer tomography shows further round foci in all lung lobes.

What is your tentative diagnosis?

  1. Streptococcal tonsillitis
  2. Tuberculosis
  3. Lemierre's syndrome
  4. Epstein-Barr virus (EBV) infection

Feel free to write us in the comments below which diagnosis you would support.

Find out here if you came up with the correct diagnosis


Fusobacterium necrophorum is detected in the blood cultures after four days. In the overall medical analysis, the diagnosis of Lemierre's syndrome is thus made.

Antibiotic therapy with ampicillin/sulbactam was initiated and supplemented with metronidazole after the diagnosis was made. The patient was discharged from hospital after five days in a significantly improved general condition. The antibiotic therapy is changed to oral and is to be taken for another four weeks.

What is Lemierre's syndrome

Lemierre's syndrome is a rare condition that occurs as a complication of tonsillitis or other infection of the ear, nose, and throat. Classically, the following triad of symptoms occurs:

  • Tonsillopharyngitis.
  • Thrombosis of the internal jugular vein.
  • Septic emboli in the lungs, and less commonly, in the brain.1

If left untreated, the disease can be fatal.

Clinical implications and diagnostics

The disease usually begins within a few days to three weeks after an upper respiratory tract infection. If there is persistent tonsillitis, swelling of the throat and shortness of breath, one should be alert and think of Lemierre's syndrome. Other possible symptoms are fever, dysphagia and meningismus.2

If suspected, blood cultures should be assayed during the fever phase, if possible. In addition, thrombosis of the IJV should be ruled out by ultrasound and a chest x-ray should be performed to rule out pneumogenic spread.


Initially, antibiotic therapy should be started quickly and broadly. If the pathogen can be detected, the antibiotic therapy can be de-escalated. Betalactam antibiotics with a beta-lactamase inhibitor (e.g. ampicillin/sulbactam) or a 3rd generation cephalosporin (e.g. ceftriaxone) combined with metronidazole are recommended. Often the response is slow even with adequate therapy, so a treatment duration of 3-6 weeks is recommended.3


  1. Lemierre A. On certain septicaemias due to anaerobic organisms. Lancet 1936; 1: 701-3.
  2. Mesrar H, Mesrar J, Maillier B, Kraoua S, Chapoutot L, Delclaux B. Syndrome de Lemierre : diagnostic, exploration, traitement Lemierre's syndrome: Diagnosis, exploration, treatment. Rev Med Interne. 2018 May;39(5):339-345.
  3. Riordan T. Human infection with Fusobacterium necrophorum (Necrobacillosis), with a focus on Lemierres syndrome. Clin Microbiol Rev 2007; 20: 622-59.

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