Garbati et al. Journal of Medical Case Reports 2012, 6:97 http://www.jmedicalcasereports.com/content/6/1/97 fluid tracked through the pre-vertebral space from the C2 down to the C6 level, with a maximum anteroposter- ior (AP) diameter of 7 mm. It tracked into the right parapharyngeal space down to the supraglottic region. The palatine tonsils were enlarged, more significantly on the right side, and showed small areas of low attenua- tion. The right internal jugular vein (IJV) showed thrombosis and enhancement of its walls (single arrow in Figure 1) that extended intracranially into the right sigmoid and transverse venous sinuses. The thrombus also extended inferiorly down to the C7 level. Other fea- tures noted on the CT included a mass effect on the oropharynx and hypopharynx as well as the larynx. A CT scan of the chest was normal. Our patient underwent incision and drainage of the abscess with no complications. He was treated with a combination of clindamycin and cefuroxime in addition to warfarin for six weeks. These interventions resulted in complete resolution of the thrombus. Normoglycemia was achieved before his discharge from hospital, and subsequent follow-up was uneventful. He was finally dis- charged from the clinic after complete wound healing and the return of his biochemical parameters to normal levels. Discussion Historically, LS has been reported to most commonly affect young, healthy adults, although cases in children have also been reported [8]. Riordan recently reviewed 222 cases of LS and reported that in up to 89% the diag- nosis was in individuals aged 10 to 35 years [9]. Since its initial description the condition has gone from being highly fatal, in the pre-antibiotic era, to a curable disease with the use of potent antimicrobials. The classic tetrad of features reported earlier in the century has given way to variants or incomplete forms of the disease with extension of the affected age group and variation in its microbiology. This has brought to the fore variants of or Lemierre-like syndromes, either due to isolation of organisms other than F. necrophorum [9] or presenta- tions that were short of the tetrad originally described or due to the involvement of anatomic structures other than those reported earlier. A retrospective review of peri-tonsillar abscesses from Saudi Arabia between 2000 and 2004 by Al-Dakhail and Khan [10] revealed that out of the 65 samples sent for culture and sensitivity, 29.6%, 21%, and 3.7% yielded normal flora, group A Strepto- cocci, and Staphylococcus aureus, respectively; while K. pneumoniae and Streptococcus viridians constituted 2.5% each of the isolates. No cases of F. necrophorum infection were reported in their patients. Some authors have questioned whether the isolation of F. necrophorum is really necessary for the diagnosis of LS [11]. Indeed a recent review reported 6% to 14% of cases of LS were Page 3 of 4 associated with either negative cultures or organisms other than F. necrophorum [9]. It is of interest to note that the isolation of F. necrophorum requires strict anae- robic culture conditions. Other reasons that could have possibly led to negative blood cultures in our patient is prior antibiotic use or that F. necrophorum was over- looked, particularly by laboratory staff unfamiliar with its typical features and characteristics. Involvement of K. pneumoniae in the causation of LS is rare, with only two previously reported cases [11,12] both of whom were also diabetic; therefore the question arose as to whether diabetes mellitus (DM) had a role in selecting this organism, or it was a mere coincidence? This association has been reported previously by Huang et al. [13], where 98.4% of their patients with diabetes had infections due to K. pneumoniae. A recent review from Singapore [14] by Lee and Kanagalingam docu- mented about 50% of their patients with diabetes with deep neck abscesses had K. pneumoniae isolated from the collections. Some of these abscesses were found to be caused by the hypermucoviscosity (HV) phenotype of K. pneumoniae, especially K1 and K2 isolates which tend to be significantly more resistant to phagocytosis than non-K1/K2 isolates [15]. Like other Gram-negative bacteria, F. necrophorum produces lipopolysaccharide, which behaves like a classi- cal endotoxin with virulence in many animal models [9]. Development of the disease has been described to occur in three stages: (1) infection of deep pharyngeal tissue; (2) invasion of the lateral pharyngeal space, resulting in IJV thrombophlebitis; and (3) embolic spread of the infection. The exact etiology and pathogenesis of LS is still unknown, but lymphatic or direct spread of infec- tion from the thrombophlebitis of the tonsillar veins causing thrombosis of the IJV due to direct involvement of the alveolar tissue of the neck has been suggested as a possible mechanism [16]. In the absence of controlled trials to determine the optimum therapy for LS, most authors based their choice of antimicrobial agent(s) mainly on personal experience and anecdotal evidence. Metronidazole is usually the most preferred agent though some authors used either a carbapenem or a penicillin/b-lactamase inhibitor combination for a total of six weeks, but the optimal duration of treatment is not known. The use of anticoagulants has been controversial, as no controlled trials exist. Some authors observed persis- tence of fever, worsening clinical condition and ongoing radiographic evidence of pulmonary emboli until full anticoagulant therapy has been initiated [17]. Routine anticoagulation is not generally required for all cases of IJV thrombosis in the absence of convincing data from randomized studies. However, anticoagulation has been frequently advocated in situations where untoward