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Lemierre’s syndrome and 2016 American College of Physician guidelines for pharyngitis: no to empiric coverage for bacterial pharyngitis. While no role for routine Fusobacterium PCR, keep suspicion for this pathogen
  1. Michael Saul Lundin1,
  2. Subash Bastakoti1,
  3. Daniel Havlichek1,2,
  4. Heather Laird-Fick1
  1. 1Department of Internal Medicine, Michigan State University, Sparrow Hospital, East Lansing, Michigan, USA
  2. 2Department of Infectious Disease, Michigan State University, Sparrow Hospital, East Lansing, Michigan, USA
  1. Correspondence to Dr Michael Saul Lundin, michael.lundin{at}


An 18-year-old woman presented to clinic with acute pharyngitis with 4/4 Centor criteria. Rapid streptococcal antigen test was negative. The patient, who was allergic to penicillin, was prescribed azithromycin. Ultimately, after 5 days and without any corticosteroids, she presented to the emergency department with 10/10 chest pain and was admitted to the intensive care unit. CT showed nodular lung disease and blood cultures on admission grew Fusobacterium, likely Fusobacterium nucleatum. She sustained two cardiac arrests, three tube thoracostomies, acute kidney injury requiring dialysis and ventilatory failure requiring tracheostomy. After 16 days in hospital and 18 days in long-term acute care, the patient was discharged home. It is unclear how much of this could have been prevented by prescribing an antimicrobial that had activity against Fusobacterium. When severe pharyngitis occurs, Fusobacterium needs to be considered as an underlying cause. In vitro macrolides have marginal activity against most anaerobes, such as this pathogen, and should be avoided.

  • infections
  • ear, nose and throat/otolaryngology
  • primary care
  • public health
  • infectious diseases

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  • Contributors MSL is the main author who thought up of the idea of the paper after we discussed pharyngitis at didactics. SB had this patient. HLF is ML’s mentor and helped out with it. DH is an infectious disease specialist attending who made substantial changes to the paper and professionalised it.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.