An unusual case of cavitating pulmonary nodules: Lemierre’s syndrome with isolated involvement of the external jugular vein

A 65-year-old female presented with symptoms of tonsillitis and sepsis. Despite initial treatment with i.v. fluid and antibiotics, her condition deteriorated and she became hypoxaemic. CT pulmonary angiography showed no filling defects in the pulmonary arteries, but there were multiple cavitating lung nodules, initially thought to represent metastases. A subsequent contrast-enhanced CT of the neck and thorax demonstrated thrombosis of the left external jugular vein (EJV), leading to a revised diagnosis of Lemierre’s syndrome (i.e. septic embolization from jugular thrombophlebitis). Noteworthy aspects of the case include the initial misdiagnosis of the cavitating lung nodules by the reporting radiologist and the isolated involvement of the EJV—Lemierre’s syndrome usually involves the internal jugular vein. The case highlights the importance of septic emboli in the differential diagnosis of cavitating lung nodules, and of assessment of the EJV as well as internal jugular vein in the context of oropharyngeal infection.