Hot Seat #192: A Sore Throat Quandary

Posted on: June 21, 2022, by :

Case by Dr. Christina Rojas, MD

HPI: 20 y/o female with a history of migraines presents with fever, sore throat, and headache for 1 day. No vomiting, diarrhea, cough, or shortness of breath. She has still been able to manage her secretions and drink liquids despite throat pain. Headache is nonfocal and feels similar to migraines she has had in the past. No vision changes, no neck pain. She is vaccinated against COVID; has never had COVID to her knowledge. She denies any sexual history. No other medical history besides migraines. 

Exam: 

VS: T 38.8, HR 132, RR 20, BP 123/76, SpO2 97% on RA

Gen: Alert, appropriate for age; appears uncomfortable, but non-toxic

Skin: No rashes

Head: Normocephalic, atraumatic

Neck: Supple, nontender

Eye: PERRL, normal conjunctiva

ENT: Oral mucosa moist, tonsils erythematous, no exudates. R tonsil with mild enlargement. Uvula midline. 

CV: Tachycardia, regular rhythm. Normal perfusion 

Respiratory: Clear bilaterally, no increased work of breathing 

GI: Soft, nontender, nondistended

Neuro: Moving all extremities equally and spontaneously, normal gait 

Lymphatics: Shotty cervical lymphadenopathy 

The patient has a strep test and COVID/Flu/RSV swab sent. She is able to tolerate liquids. She receives ibuprofen and her repeat VS are: T 37.7, HR 109, RR 18, BP 117/70, SpO2 99% on RA. She is discharged home. 

Two days later, she returns to the ED with persistent fever, headache, and sore throat. She says her headache is throbbing, severe, and associated with photophobia – similar to her prior migraines, but seems a bit worse than usual. She also notes that her right ear and the right side of her neck hurt. She has still been able to drink. No voice changes or drooling. No respiratory symptoms or neurologic deficits. Her strep and COVID/RSV/Flu from two days ago were all negative. 

Exam:

VS: T 38.8, HR 139, RR 20, BP 117/79, SpO2 98% on RA

Gen: Appears uncomfortable, though nontoxic and normal mental status

Skin: No rashes

Head: Normocephalic, atraumatic

NeckMild tenderness to palpation of R anterior and R lateral neck. No masses appreciated, no overlying skin changes

Eye: PERRL, normal conjunctiva

ENT: R TM erythematous, no purulence; oral mucosa moist, tonsils erythematous, no exudates. R tonsil with mild enlargement. Uvula midline. 

CV: Tachycardia, regular rhythm. Normal perfusion 

Respiratory: Clear bilaterally, no increased work of breathing 

GI: Soft, nontender, nondistended

Neuro: Moving all extremities equally and spontaneously, normal gait 

Lymphatics: Shotty cervical lymphadenopathy 

CBC, CRP, ESR, and RVP are ordered. CBC: 9.21 < 13.1 > 219. 0.9 bands (H), 8.12 ANC (H). ESR 63 (normal: 0-20), CRP 16.68 (normal: <0.5). RVP is negative. CXR is negative. US of neck is performed and notes possible right-sided sialadenitis, but no evidence of abscess. She is given ketorolac and prochlorperazine for migraine, and her headache improves. She is able to tolerate PO and is discharged home. 

The next day, she returns again to the ED. She has now had 5 days of fever, headache, throat pain, R neck pain, R ear pain, and recently developed vomiting and diarrhea over the past few hours. She denies abdominal pain, respiratory distress, dysuria, or rashes. She denies sexual activity. She is tired-appearing, but her mental status is normal. Her exam is unchanged when compared to the day prior. VS: VS: T 38.5, HR 137, RR 20, BP 110/75, SpO2 99% on RA.

Walter Palmer
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4 thoughts on “Hot Seat #192: A Sore Throat Quandary


  1. Agree with above. The continued symptoms, significant pain and fever raise the concern for a deep neck infection. The indolent course and progressively increasing pain is concerning for Lemierre Syndrome. My question is the sensitivity of a soft tissue US for identifying this, since a doppler study of the jugular vein is needed. If US is not sufficient, the next study is a CT neck with contrast, potentially including brain if concerns for infectious extension.


  2. Agree with above. The continued symptoms, significant pain and fever raise the concern for a deep neck infection. The indolent course and progressive symptoms are consistent with Lemierre Syndrome. My question is whether the soft tissue US is sufficient to exclude this diagnosis. It may not, as a a doppler query of the jugular vein is needed. If another imaging test is needed, a CT neck with contrast would be my choice, potentially with brain imaging to look for infectious extension.


  3. I am curious to know how her exam has changed at this final visit. What made her return again, was it simply persistent symptoms or the new GI symptoms? If her headache is progressively worsening despite interventions I might consider adding a CT brain to the CT neck as Jennifer suggests above.

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