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Patient: Female, 66-year-old Final Diagnosis: Lemierre’s syndrome Symptoms: Chills • neck pain • odynophagia • rigors • trismus Medication: — Clinical Procedure: Computed tomography Specialty: Cardiology • Hematology • Infectious Diseases • General and Internal Medicine Objective: Unusual clinical course Background: Lemierre’s syndrome (LS), a potentially fatal condition, is characterized by thrombophlebitis of a head or neck vein secondary to a head or neck infection, most commonly involving Fusobacterium necrophorum. Its association with polycythemia vera (PV) is not well reported despite the predisposition to thrombogenesis. Case Report: We present the case of a 66-year-old woman with a known history of polycythemia vera (PV) who presented with 4 days of worsening right-sided neck pain and odynophagia. The physical examination revealed poor oral dentition, mild erythema of the posterior pharyngeal mucosa, and non-erythematous tonsils without exudate. A computed tomography with i.v. contrast of the neck revealed complete thrombosis of the right internal jugular vein (IJV). Treatment was initiated with i.v. antibiotics and anticoagulation, with symptoms improving rapidly within 24 h. She was eventually discharged on apixaban and clindamycin and was encouraged to follow up with her hematologist. Conclusions: PV predisposes patients to a hyper-viscous and prothrombotic state, which may warrant a stronger suspicion of Lemierre’s syndrome. In addition, lack of aspirin use for prophylaxis of thrombosis and undiagnosed oral infection are factors to consider when assessing risk factors for Lemierre’s syndrome in PV patients.

Patient: Female, 74-year-old Final Diagnosis: Mucormycosis Symptoms: Altered mental status Medication:— Clinical Procedure: Central venous catheterization • debridement Specialty: Infectious Diseases • General and Internal Medicine • Otolaryngology Objective: Unusual clinical course Background: Invasive mucormycosis is a rare, life-threatening infection that requires urgent medical management. Here we describe a patient who developed invasive mucormycosis after receiving only a short course of dexamethasone. The purpose is to highlight this atypical presentation of a rare disease. Case Report: A 74-year-old woman with a medical history of diabetes mellitus (DM), hypertension, hyperlipidemia, and small cell lung cancer with metastasis to the brain presented to the Emergency Department with altered mental status and a hyperosmolar hyperglycemic state. Three weeks before, she had been diagnosed with DM (hemoglobin A1c [HbA1c] 6.5%) and was started on dexamethasone to treat cerebral edema. On admission, her HbA1c was 10.8%, although she had received only a short course of dexamethasone. Her physical exam was concerning for left eyelid swelling and ophthalmoplegia. Computed tomography of the head and neck revealed signs of left ocular proptosis and invasive rhinomaxillary fungal disease. The patient underwent urgent surgical debridement; subsequent magnetic resonance imaging revealed extensive fungal disease extending into her left inferior frontal lobe. A surgical pathology report was positive for Rhizopus oryzae and Stenotrophomonas maltophilia. Her blood cultures were positive for methicillin-susceptible Staphylococcus aureus. She was treated with antibiotics and amphotericin B. Her clinical course was complicated by hypokalemia. She eventually recovered and was discharged from the hospital. Conclusions: This case highlights an atypical presentation of mucormycosis. Clinicians should remain vigilant for this rare complication of dexamethasone use even when the therapy is given for a short time.