In a female with a sore throat lasting more than two weeks that radiates to the right ear, no fever or chills, and a five‑week cough with shortness of breath, what is the likely diagnosis and appropriate work‑up and treatment?

Prolonged Sore Throat with Ear Pain and Chronic Cough: Likely Diagnosis and Management

This patient requires urgent evaluation for Lemierre's syndrome or other serious complications of pharyngitis, given the prolonged duration (>14 days) and referred otalgia, which places her outside standard acute sore throat guidelines and warrants immediate imaging and blood cultures.

Why This Case is High-Risk

The ESCMID guideline explicitly excludes persistent sore throat (>14 days duration) from standard acute pharyngitis management 1. This patient's symptoms have persisted for over two weeks with ear radiation, which is a red flag. A case report demonstrates that persistent sore throat can herald Lemierre's syndrome—internal jugular vein thrombosis with fusobacterium bacteremia—which presents exactly like this: prolonged sore throat that fails to improve 2.

Immediate Work-Up Required

Critical Investigations

• Blood cultures (to detect fusobacterium necrophorum or other bacteremia) 2
• Inflammatory markers (CRP, ESR, CBC with differential) 2
• CT neck with IV contrast or ultrasound of neck vessels to evaluate for internal jugular vein thrombosis 2
• Chest imaging given the 5-week cough with shortness of breath—this could represent septic emboli if Lemierre's is present, or alternative diagnoses like atypical pneumonia

Additional Considerations

• Throat culture or rapid strep test (though less likely given duration and lack of fever)
• Consider testing for Mycoplasma pneumoniae and Chlamydia pneumoniae given the prolonged cough 1
• Laryngoscopy if concern for malignancy (chronic symptoms, unilateral ear pain can indicate referred pain from laryngeal/pharyngeal pathology)

Differential Diagnosis Priority

1. Lemierre's syndrome (suppurative thrombophlebitis of internal jugular vein)
2. Peritonsillar or retropharyngeal abscess (though typically presents with fever)
3. Malignancy (pharyngeal, laryngeal, or thyroid—unilateral ear pain is classic referred pain)
4. Atypical bacterial infection (Mycoplasma, Chlamydia pneumoniae causing both pharyngitis and bronchitis) 1
5. Chronic bronchitis with separate pharyngeal pathology 3

Treatment Approach

If Lemierre's Syndrome Confirmed

• Immediate IV antibiotics: broad-spectrum coverage for anaerobes (metronidazole or clindamycin) plus coverage for streptococci
• Anticoagulation (controversial but often used for internal jugular thrombosis)
• Hospital admission for IV therapy

If Imaging/Cultures Negative

• Penicillin V 500mg TID for 7 days remains first-line if bacterial pharyngitis suspected (clarithromycin if penicillin-allergic) 4, 5
• Symptomatic treatment: ibuprofen or naproxen for throat pain 4, 5
• For the cough: The CHEST guideline on acute bronchitis notes most cases are viral and self-limited, but 5 weeks exceeds typical acute bronchitis duration (≤3 weeks) 3—consider post-infectious cough, pertussis, or atypical pneumonia

Critical Pitfalls to Avoid

Do not treat this as simple acute pharyngitis. The >14-day duration automatically excludes her from standard sore throat guidelines 1. The combination of:

• Prolonged symptoms (>2 weeks throat, 5 weeks cough)
• Referred otalgia (suggests deeper pathology)
• Respiratory symptoms (shortness of breath)

...mandates investigation for serious complications before empiric antibiotic treatment.

Do not dismiss the absence of fever. Lemierre's syndrome can present without high fever initially, and the case report specifically notes this presentation pattern 2.

Algorithmic Approach

1. Immediate: Order blood cultures, inflammatory markers, and neck imaging
2. Same day: Obtain chest X-ray (minimum) given dyspnea and 5-week cough
3. If imaging shows thrombosis or abscess: Admit for IV antibiotics and possible surgical drainage
4. If imaging negative but high inflammatory markers: Consider empiric antibiotics for deep space infection while awaiting cultures
5. If all negative: Consider ENT referral for laryngoscopy to rule out malignancy, and pulmonary evaluation for chronic cough

The key message: duration >14 days + referred ear pain = not a simple sore throat. Image the neck and get cultures before assuming this is benign pharyngitis.