Hrev_master Dear Editor, A recent publication by Drei et al.1 discusses a case involving a young male patient diagnosed with Lemierre Syndrome (LS), who was successfully treated with prolonged antibiotic therapy and anticoagulants without the need for surgery, resulting in a complete clinical recovery. The article provides a comprehensive overview of the epidemiology, aetiology, and treatment options for LS. It highlights the concerning link between a patient’s young age and the potential for severe complications, which could lead to a fatal outcome if diagnosis and treatment are delayed. We would like to share a similar experience to underscore the critical role of emergency doctors in the early diagnosis and treat- ment of LS, which is essential for preventing fatal consequences. Recently, we diagnosed LS in a 27-year-old male patient who presented to our emergency department with fever, sore throat, and neck pain persisting for 4 days, unresponsive to NSAIDs. He had minimal trismus and a left peritonsillar swelling with initial fistuli- sation. Portable endoscopy showed moderate medialization of the left lateral oropharyngeal wall, bulging of the left hemipalate, and a normal larynx. Exploratory punctures at several sites yielded purulent material. A color Doppler ultrasound (US) of the neck was immediately performed, revealing complete thrombosis of the left internal jugular vein with normal flow in the homolateral subcla- vian vein (video 1). A total-body CT scan with contrast confirmed the rhino-pharyngeal abscess (Figure 1) with the thrombosis of both left internal and external jugular vein (Figure 2) and revealed septic emboli in both lungs (Figure 3). An MRI of the neck ruled out spondylodiscitis and osteomyelitis. Colour Doppler echocar- diography excluded endocarditis and pericardial effusion. HIV, HCV, HBV, and tuberculosis infections were excluded. On admis- sion, laboratory tests showed neutrophil leucocytosis (WBC 20,270/mm3, neutrophils 92%), slight thrombocytopenia (84,000/mm3), and increased values of C-reactive protein (44 mg/dL, normal value <0.5), procalcitonin (23 ng/mL), D-dimer (62,000 ng/mL), and transaminases (AST 41 U/L, ALT 39 U/L, normal values 10-37). Empiric antibiotic therapy with piperacillin/tazobactam (4.5 g IV q6h) and subcutaneous anticoag- ulation with low molecular weight heparin (100 U/Kg q12h) were started immediately. After 12 hours, the blood cultures resulted positive for multisensitive Fusobacterium necrophorum and nucleatum. The patient’s clinical course showed progressive improvement without severe complications such as pleural empyema, pul- monary abscesses, or mediastinitis. Surgical treatment, mechanical ventilation, or vasoactive agents were not necessary. The patient was discharged after 18 days of recovery, prescribed oral amoxi- cillin/clavulanate (875/125 mg, one tablet every 8 hours) and edox- aban (60 mg, one tablet daily). The follow-up CT scans of the neck and chest, performed 2 and 3 weeks later, respectively, showed a complete resolution of the abscess with the partial recanalization of the left internal jugular vein and a remarkable reduction in pul- monary septic emboli. Consequently, antibiotic therapy was dis- continued, while oral anticoagulant was continued due to persistent jugular vein thrombosis with partial recanalization observed on US. Laboratory tests showed normal full blood counts, hepatorenal function, and C-reactive protein levels. We would like to emphasize three key points regarding the role of emergency doctors in the diagnosis and management of patients with LS. First, it is crucial to promptly identify Fusobacterium necrophorum for appropriate antibiotic treatment. We strongly rec- ommend alerting the laboratory for the identification of this pathogen, as it is not routinely detected - particularly in the pharyn- geal swabs – and blood cultures could result false negatives unless Emergency Care Journal 2025; volume 21:14033 [Emergency Care Journal 2025; 21:14033] [page 87] Comments on From a sore throat to Lemierre syndrome. A case report and literature review Erika Poggiali,1 Davide Gallo,1 Alessandro Dacrema,1 Camilla Botti,2 Beatrice Rossi,2 Claudia Caborni,2 Andrea Vercelli1 1Emergency Department, Guglielmo da Saliceto Hospital, Piacenza; 2Radiology Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy Correspondence: Erika Poggiali, Emergency Department, “Guglielmo da Saliceto” Hospital, via Giuseppe Taverna 49, Piacenza, Italy. Tel.: +39.0523.303044. E-mail: E.Poggiali@ausl.pc.it Keywords: Lemierre syndrome, Fusobacterium necrophorum, pharyngotonsillitis, jugular vein thrombosis. Contributions: EP drafted the manuscript. EP, DG, CB, BR, CC col- lected details of the case and cared for the patient. AD and AV criti- cally revised the manuscript. All the authors approved the final ver- sion. Conflict of interest: EP is member of the editorial board of Emergency Care Journal. The authors declare no potential conflict of interest, and all authors conform accuracy. Availability of data and materials: all data underlying the findings are fully available upon reasonable request to Erika Poggiali, E.Poggiali@ausl.pc.it Ethics approval and consent to participate: not applicable. Informed consent: The patient provided consent for the access to medical records at the time of admission. Received: 26 May 2025. Accepted: 10 June 2025. Early view: 12 June 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Emergency Care Journal 2025; 21:14033 doi:10.4081/ecj.2025.14033 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Letter [page 88] [Emergency Care Journal 2025; 21:14033] Figure 1. CT scan of the neck showing rhino-faryngeal abscess (red arrows). Figure 2. CT scan of the neck showing complete thrombosis of the left jugular vein (red arrows). Figure 3. Chest CT scan with contrast showing septic emboli in both the lungs (red arrows). a direct PCR method is used.2 Second, because septic emboli can spread to various organs, including the brain, lungs, kidneys, and heart, a brain and total- body CT scan with contrast is imperative in all cases. We are aware that the brain involvement is rare, but over 10% of the patients suf- fer from permanent neurological sequelae,3 which can include cra- nial nerves and limb paresis, blindness, and decreased visual acu- ity. Given this evidence, a comprehensive neurological evaluation is essential upon admission to the emergency department and should be repeated throughout the recovery process. Finally, as emergency doctors, we recommend using bedside US to investigate possible jugular vein thrombosis in all young patients presenting with pharyngotonsillitis. We believe that the incidence of LS is underestimated due to incomplete evaluations. Therefore, assessments should always include neck color Doppler US to ensure early diagnosis of vein thrombosis. This approach can not only help to treat LS correctly but also prevent the progres- sion from a localized infection to multiorgan failure, which has a high mortality rate. In conclusion, emergency doctors should always consider LS when evaluating a young patient with an oropharyngeal infection. References 1. Drei A, Rava G, Predieri S, et al. From a sore throat to Lemierre syndrome. A case report and literature review. Emerg Care J 2025; https://doi.org/10.4081/ecj.2025.13720 2. Xie M, Liu J, Zheng J, et al. Lemierre syndrome: report of a case with an innovative diagnostic method and literature review. Infect Drug Resist 2024;17:1-10. 3. Vu VN, Savino PJ, Robbins SL. Bilateral abducens nerve palsy due to septic thrombophlebitis. Am J Ophthalmol Case Rep 2019;16:100566. Letter [Emergency Care Journal 2025; 21:14033] [page 89] Supplementary Materials Video 1. US performed at bedside on admission in the emergency department showing a left jugular vein thrombosis.