A 28-year-old man presented with fever, pharyngitis and cervical lymphadenopathy after returning from the Solomon Islands 2 days prior to his presentation. His past medical history was notable for CGD, which was diagnosed as a child following presentations with recurrent pneumonia and sinusitis. He was treated for pulmonary tuberculosis at age 4 years, but subsequently presented 2 years prior to his current admission with left upper lobe cavitary lung lesions and was retreated for culture-negative tuberculosis with rifampicin, isoniazid, pyrazinamide and ethambutol.
One month prior to his current admission, the patient travelled to rural areas of the Solomon Islands. The patient was not taking his antibiotic prophylaxis at the time. He described both fresh and salt-water contact with a number of lacerations on his feet, although none of these became inflamed or infected. One week prior to return to Australia, he became unwell with a prominent sore throat, fever and subsequent neck pain. After arrival in Australia, he presented to our institution.
On examination the patient was febrile (39  C), had significant hypotension [systolic blood pressure 70 mmHg (9.3 kPa)], a pulse rate of 160 beats min-1, a respiratory rate of 24 breaths min-1 and an oxygen saturation of 93 % on room air. His neck was asymmetrically swollen on the left, without any fluctuance. The oropharynx was erythematous and oedematous without a visible collection or any evidence of airway compromise. The lacerations on his feet were all well healed, with no evidence of inflammation.
Initial tests revealed an elevated total white cell count (17x109 cells l-1) and neutrophils (10.2x109 cells l-1), C-reactive protein of 286 mg l-1 and a lactate level of 3.2 mmol l-1. A chest X-ray demonstrated a new opacity in his left lower lobe. Arterial blood gases demonstrated pH 7.44, pO265 mmHg (8.7 kPa) and pCO232 mmHg (4.3 kPa). Ultrasonography of his neck revealed an occlusive thrombus of the left mid to upper internal jugular vein. This was subsequently confirmed with computed tomography (CT), which demonstrated thrombosis of the left internal jugular vein at the level of the thyroid cartilage, extending superiorly to the base of skull (Fig. 1). The CT imaging also demonstrated centrally necrotic consolidation in the anterior left lower lobe and multiple ill-defined pulmonary nodules. These clinical and imaging findings were consistent with Lemierre's syndrome, that is, internal jugular vein thrombophlebitis.