SEPTIC THROMBOPHLEBITIS AND EMBOLIC COMPLICATIONS IN AN 18-YEAR-OLD MALE: A RARE CASE OF REVERSE LEMIERRE’S SYNDROME

Suryawanshi HK, Biradar S, Thakur MB. Septic thrombophlebitis and embolic complications in an 18-year-old male: a rare case of reverse Lemierre’s Syndrome. International Journal of Infection. 2025;9(2):34-38.

H.K. Suryawanshi, S. Biradar and M.B. Thakur^*

Department of Internal Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.

*Correspondence to:
Dr. Manisha Bais Thakur, MD, FICP,
Department of Internal Medicine,
Vardhman Mahavir Medical College and Safdarjung Hospital,
New Delhi, India.
e-mail: hodmedicine2015@gmail.com

Received: 03 July, 2025 Accepted: 08 August, 2025

ISSN 1972-6945 [online] Copyright 2025 © by Biolife-publisher This publication and/or article is for individual use only and may not be further reproduced without written permission from the copyright holder. Unauthorized reproduction may result in financial and other penalties. Disclosure: all authors report no conflicts of interest relevant to this article.

ABSTRACT

Reverse Lemierre’s syndrome (RLS) is a rare and potentially life-threatening condition defined by septic thrombophlebitis arising from an extra-oropharyngeal source, often leading to the development of septic emboli. We present the case of an 18-year-old male who developed RLS following right thigh pyomyositis precipitated by a minor muscular strain. This case illustrates the clinical features, diagnostic steps, and treatment decisions required for managing RLS. Making the diagnosis promptly is vital, and a combination of tools, including ultrasound, MRI, and CT pulmonary angiography, can help pinpoint the condition early, allowing for timely and effective intervention. In this patient, a multidisciplinary approach combining targeted antibiotics, anticoagulation, and surgical drainage led to a successful recovery. This case highlights the need to consider uncommon sources of sepsis in young patients, as early recognition and timely intervention can greatly improve their outcomes.

KEYWORDS: Reverse Lemierre’s syndrome, pyomyositis, septic pulmonary embolism, deep vein thrombosis, Staphylococcus aureus

INTRODUCTION

Lemierre’s syndrome, also known as post-anginal septicemia or necrobacillosis, was first reported in 1890 by Courmont and Cade. However, it was more comprehensively described in 1936 by André Lemierre, a French physician and professor of microbiology, in a review of 20 cases published in the Lancet (1). Lemierre’s syndrome refers to thrombophlebitis of the internal jugular vein accompanied by bacteremia, typically following an oropharyngeal infection and most often caused by anaerobic bacteria. When a similar thrombotic and infectious process occurs in the lower limb, it is termed reverse Lemierre’s syndrome (2). Fusobacterium necrophorum is a gram-negative anaerobe that can cause localized throat infections or severe systemic illness. Systemic involvement is known as Lemierre’s syndrome, post-anginal sepsis, or necrobacillosis (3).

Pyomyositis is a primary bacterial infection of the skeletal muscles, commonly referred to as tropical myositis due to its higher prevalence in individuals residing in tropical regions. The condition is often diagnosed late, leading to increased morbidity and, in some cases, significant mortality (4). Staphylococcus species, particularly Staphylococcus aureus, are the most common causative organisms in pyomyositis, especially when the lower limbs are involved, accounting for approximately 90% of cases (5). Unlike classical Lemierre’s syndrome, reverse Lemierre’s syndrome often lacks ENT symptoms, making early diagnosis difficult. This case describes a healthy young male who presented with fever and limb pain, later found to have thigh pyomyositis, femoral vein thrombosis, and septic pulmonary emboli. It highlights the need for early imaging and clinical suspicion in atypical sepsis presentations.

CLINICAL PRESENTATION

An 18-year-old previously healthy male presented with high-grade fever and painful swelling of the right thigh for three days. He reported a history of thigh strain sustained while carrying a heavy water jar downstairs. The next day, he developed worsening pain and diffuse swelling in the right thigh, restricting movement. Fever with chills followed, partially relieved by over-the-counter medication. He was initially evaluated at a local hospital for sepsis with polyarthralgia and referred to our center for further management.

At admission, he was febrile (103°F), conscious, and oriented. Vitals included pulse 104 bpm, blood pressure 118/80 mmHg, respiratory rate 24/min, and oxygen saturation 94% on room air. Bilateral rales were heard on chest auscultation. Local examination revealed diffuse swelling, warmth, and tenderness in the right thigh without rash or lymphadenopathy (Fig.1).

Fig. 1. Right thigh swelling- vastus lateralis pyomyositis.

INVESTIGATIONS

Initial blood work showed hemoglobin 10.3 g/dL, leukocyte count 28,000/mm³ (later peaking at 34,000/mm³), and platelet count 75,000/mm³. Inflammatory markers were elevated: ESR 30 mm/hr and CRP >100 mg/L. Liver and renal function tests were within normal limits. Blood sugar was 104 mg/dL. Tests for malaria, dengue, enteric fever, rickettsial diseases, HIV, hepatitis B, and C were negative.

Aspiration of the thigh collection revealed purulent fluid, which cultured methicillin-sensitive Staphylococcus aureus (sensitive to clindamycin, vancomycin, and cefoxitin). Ultrasound of the right thigh identified a 16 × 1.8 cm collection in the vastus lateralis with diffuse edema, confirmed by MRI as pyomyositis. Doppler ultrasound showed deep vein thrombosis involving the distal saphenofemoral and popliteal veins, consistent with septic thrombophlebitis.

Chest radiograph revealed bilateral peripheral opacities and consolidation. CT pulmonary angiography demonstrated scattered peripheral and subpleural consolidations with areas of cavitation and mild bilateral pleural effusion, indicative of septic pulmonary embolism (Fig.2,3).

Fig. 2. Chest radiograph showing bilateral peripheral radiodense shadows suggestive of consolidation.

Fig. 3. CT of the thorax revealing multiple scattered consolidations with areas of breakdown in peripheral and subpleural locations, along with bilateral mild pleural effusion, suggestive of septic pulmonary embolism.

TREATMENT AND OUTCOME

Empirical broad-spectrum antibiotics were initiated and later tailored to vancomycin and clindamycin based on sensitivity. Anticoagulation was started with low molecular weight heparin, followed by oral dabigatran. Due to the progression of pyomyositis, surgical drainage was performed, yielding approximately 200 mL of pus. The patient showed rapid clinical improvement, became afebrile within five days, and maintained normal oxygen saturation on room air. Mobility progressively returned, and he was discharged in stable condition after 10 days of hospitalization. He continues to do well on follow-up.

DISCUSSION

What made this case particularly remarkable was the co-existence of seemingly unrelated septic processes, namely, pneumonia and pyomyositis, alongside deep vein thrombosis (DVT). Initially, we considered these findings to be separate complications. However, their concurrent presentation prompted us to reassess the etiology and look for a unifying diagnosis. The discovery of DVT adjacent to the inflamed thigh muscle was especially perplexing.

Septic pulmonary embolism (SPE) is an uncommon form of pulmonary embolism caused by the embolization of infected thrombi to the pulmonary arterial circulation, leading to clinical and radiological findings such as peripheral consolidations, empyema, pleural effusion, and lung abscesses. In 1978, a study reported 60 cases of septic pulmonary embolism, 78% of which occurred in intravenous drug users. Since then, with the growing use of intravascular devices and catheters, an increasing number of catheter-related SPE cases have been described in the literature (6,7)

A systematic review by Rui Ye et al. analyzed 168 cases of septic pulmonary embolism, identifying a range of primary infection sources. The most common were intravenous drug use (26.19%), followed by indwelling intravascular catheters (12.5%), infective endocarditis (11.9%), and liver abscesses (8.93%). Other significant sources included skin and soft tissue infections (5.95%), septic thrombophlebitis (5.95%), and dental and periodontal infections (5.36%). Notably, Lemierre’s syndrome accounted for 5.36% of cases, while pyomyositis was identified in only four instances, underscoring its rarity but reinforcing its potential role as an underlying cause (8).

Septic thrombophlebitis can theoretically involve any vein, whether superficial or deep. Its diagnosis is established based on clinical presentation, culture results, and radiographic evidence of venous thrombosis. A retrospective case series by Jorge A. Brenes et al. highlights that the coexistence of an extrapulmonary infection with contiguous septic thrombophlebitis and subsequent septic pulmonary embolism occurs in both adults and children (9). In this process, a localized infection allows organisms, typically bacteria, to invade the venous system, where associated edema may compress the vein and cause stasis. Once in the bloodstream, endothelial injury from toxins and inflammatory mediators, along with direct thrombotic effects of the pathogen, promotes thrombus formation. The resulting fibrin and platelet matrix provides an ideal environment for bacterial growth and propagation, serving as a source for metastatic infection as fragments embolize to the pulmonary circulation (10).

Pyomyositis is an acute infection of striated muscle that can present as a localized abscess or an aggressive, necrotic process. It can be classified as primary or secondary to a nearby or remote site of infection. Primary pyomyositis is rare, typically affecting children and adolescents, with the large muscles of the lower limbs being the most common site (11). It is especially prevalent in tropical regions such as Africa and the South Pacific, earning it the name tropical pyomyositis. The condition is more frequently seen in immunocompromised patients, though it can also arise due to local muscle factors such as trauma or vigorous exercise. It is believed that pyomyositis develops when a hematoma within a muscle following trauma becomes secondarily infected during an episode of bacteremia (12). The most common pathogen is Staphylococcus aureus (accounting for 70–90% of cases), while other organisms, such as Streptococcus pyogenes, Neisseria gonorrhoeae, Enterococcus faecalis, Escherichia coli, Salmonella enteritidis, and Mycobacterium tuberculosis, have also been implicated (13).

Management of this condition requires a multidisciplinary approach. In our patient, clinical improvement was achieved through culture-guided antibiotic therapy, anticoagulation, and surgical drainage. Although the role of anticoagulation in septic thrombophlebitis remains controversial, Valerio et al. have suggested a potential benefit in reducing further thromboembolic complications (14). Surgical drainage is critical for eliminating the suppurative focus and is indicated when swelling progresses with an imminent risk of compartment syndrome. The prognosis improves significantly with early diagnosis, allowing timely intervention and facilitating patient recovery.

This case is particularly notable not only for the presence of a rare clinical triad but also for its occurrence in a young, immunocompetent individual. It emphasizes the importance of maintaining a high index of suspicion and integrating subtle clinical cues when managing complex sepsis presentations. This case is the fourth such instance of this triad reported worldwide. The first was described in France in a soccer player, and two subsequent cases have been reported from India, one in an elderly diabetic male and another in a 17-year-old boy (2,15,16).

Conflict of interest

The authors declare that they have no conflict of interest.

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