Streptococcus constellatus-Associated Lemierre Syndrome Presenting With Cavitating Septic Pulmonary Emboli Managed by Video-Assisted Thoracoscopy

BACKGROUND Lemierre syndrome is a rare septic thromboembolic disorder. Although historically associated with Fusobacterium necrophorum, non-fusobacterial cases caused by Streptococcus constellatus can present with dominant thoracic sepsis and delayed recognition. CASE REPORT A 25-year-old previously healthy man from northern Ecuador presented with 7 days of dyspnea, productive cough, fever, and hemoptysis, with profound hypoxemia and respiratory distress. Chest computed tomography showed bilateral cavitating septic pulmonary emboli and necrotizing pulmonary infection, and cervical vascular imaging confirmed left internal jugular vein thrombosis. One blood culture set grew Streptococcus constellatus susceptible to penicillin and ceftriaxone; sputum and pleural fluid cultures were sterile. He required intensive care, endotracheal intubation, empiric piperacillin-tazobactam plus vancomycin, escalation to meropenem plus vancomycin during clinical deterioration while resistant or polymicrobial infection was considered, therapeutic anticoagulation, and 2 video-assisted thoracoscopic procedures for empyema and a subsequent pulmonary abscess. After 4 weeks of intravenous antibiotics, he improved and was discharged on a direct oral anticoagulant for 1 additional month, remaining asymptomatic at short-term follow-up. CONCLUSIONS Lemierre syndrome should be considered in young adults with severe sepsis and multifocal cavitating lung lesions, even without pharyngeal symptoms. Empiric therapy should initially cover oral aerobes and anaerobes; once penicillin-susceptible Streptococcus constellatus is confirmed and no co-pathogen is recovered, de-escalation to targeted beta-lactam therapy, such as penicillin G or ceftriaxone, should be considered together with drainage of empyema or abscess when present.