The Long and Winding Road
Sometimes a difficult diagnosis is made by skill, and other times by happenstance. This case required a bit of both.
A four year old boy complained of fever, headache, and neck pain for 1-2 days. His pediatrician had evaluated him that morning, found no evidence of bacterial infection and recommended supportive care. When the headache worsened and the patient could not move his neck without screaming, the family sought medical attention later that evening. He denied any sore throat, earache, or pain with swallowing. There was no cough, vomiting, or diarrhea, but the family admitted to decreased oral intake that day. The worst pain was apparently in the left parietal area, and was only partially relieved by Tylenol at home. His parents were very concerned about the possibility of meningitis.
He had a temperature of 103 orally, a heart rate of 150, and he was alert but moderately lethargic. His respiratory rate was slightly increased but not labored. Although his tonsils were symmetrically enlarged, they were otherwise normal without erythema or exudates. His tympanic membranes were normal. His neck was supple with no meningeal signs, but revealed multiple small anterior cervical and submandibular lymph nodes bilaterally which were mildly tender to palpation. He complained of neck pain when he rotated his head, but not with flexion. The rest of his exam was unremarkable.
His rapid strep and rapid influenza tests were both negative. His WBC was 22,000 with neutrophilic predominance. A lumbar puncture was performed which revealed an opening pressure of 27cm (normal is 5-15cm), but the spinal fluid was clear with essentially normal laboratory studies. The patient received IV Rocephin pending the CSF results. Because of the elevated opening pressure in the setting of normal CSF studies, I ordered a CT scan of the brain which was initially reported as entirely normal by the Radiologist.
By this time, the patient's headache and fever were only distant memories after his one dose of Motrin and generous IV fluid replacement. He was hungry and his family was eager to take him home, relieved at the good news. His Pediatrician was likewise thrilled and agreed to see him in the office the following morning.
As I was preparing the discharge paperwork, the Radiologist called back to tell me that she had reviewed the CT scan again and noticed a retropharyngeal abscess that she had initially overlooked. Oops. That changes everything.
Indeed. Neither is the workup.
The head CT scan was only questionably indicated in the first place, and it was fortunate that the retropharyngeal infection was visible on the brain scan at all.
(images courtesy of the link above...my patient's abscess was a bit more subtle)
A four year old boy complained of fever, headache, and neck pain for 1-2 days. His pediatrician had evaluated him that morning, found no evidence of bacterial infection and recommended supportive care. When the headache worsened and the patient could not move his neck without screaming, the family sought medical attention later that evening. He denied any sore throat, earache, or pain with swallowing. There was no cough, vomiting, or diarrhea, but the family admitted to decreased oral intake that day. The worst pain was apparently in the left parietal area, and was only partially relieved by Tylenol at home. His parents were very concerned about the possibility of meningitis.
He had a temperature of 103 orally, a heart rate of 150, and he was alert but moderately lethargic. His respiratory rate was slightly increased but not labored. Although his tonsils were symmetrically enlarged, they were otherwise normal without erythema or exudates. His tympanic membranes were normal. His neck was supple with no meningeal signs, but revealed multiple small anterior cervical and submandibular lymph nodes bilaterally which were mildly tender to palpation. He complained of neck pain when he rotated his head, but not with flexion. The rest of his exam was unremarkable.
His rapid strep and rapid influenza tests were both negative. His WBC was 22,000 with neutrophilic predominance. A lumbar puncture was performed which revealed an opening pressure of 27cm (normal is 5-15cm), but the spinal fluid was clear with essentially normal laboratory studies. The patient received IV Rocephin pending the CSF results. Because of the elevated opening pressure in the setting of normal CSF studies, I ordered a CT scan of the brain which was initially reported as entirely normal by the Radiologist.
By this time, the patient's headache and fever were only distant memories after his one dose of Motrin and generous IV fluid replacement. He was hungry and his family was eager to take him home, relieved at the good news. His Pediatrician was likewise thrilled and agreed to see him in the office the following morning.
As I was preparing the discharge paperwork, the Radiologist called back to tell me that she had reviewed the CT scan again and noticed a retropharyngeal abscess that she had initially overlooked. Oops. That changes everything.
A retropharyngeal abscess is an infection in one of the deep spaces of the neck. An abscess in this location is an immediate life-threatening emergency, with potential for airway compromise and other catastrophic complications. Retropharyngeal abscess is almost exclusively a pediatric diagnosis. Most incidents occur in children aged 6 months to 6 years, with a mean age of 3-4 years. Since the advent and widespread use of antibiotics in treatment of URIs, incidence of retropharyngeal abscess has declined considerably, and it is now relatively uncommon.
Patients with retropharyngeal abscess present with constitutional complaints such as fever, chills, malaise, decreased appetite, and irritability. Patients may complain of sore throat, difficulty swallowing (dysphagia), pain on swallowing (odynophagia), jaw stiffness (trismus), or neck stiffness (torticollis). Patients also may complain of muffled voice, the sensation of a lump in the throat, and/or pain in the back and shoulders upon swallowing. Difficulty breathing is an ominous complaint that signifies impending airway obstruction. Patient history is not always straightforward.
Indeed. Neither is the workup.
The head CT scan was only questionably indicated in the first place, and it was fortunate that the retropharyngeal infection was visible on the brain scan at all.
(images courtesy of the link above...my patient's abscess was a bit more subtle)
Labels: medical, patients, spinal tap
posted by scalpel at 10:15 AM
15 Comments:
Cool, you taught me something new, I didn't know such a thing existed. I, like the parents, was thinking meningitis...
Very nice catch. I actually guessed this, but only because I knew if you were going to blog about something it was going to be some kind of zebra. I've never seen an actual case.
What happened? Does ENT manage this, or maybe IR? Do they give IV antibiotics a chance first?
Interesting - in our part of the world (NZ) we frequently see retropharangeal abscesses - including adults. And his strep titres were normal?
Why was the LP opening pressure elevated?
The rapid strep test was negative. I don't know what the culture showed.
I'm still not sure why the CSF pressure was elevated, but if it wasn't I never would have ordered the CT scan. That's the lucky part.
Why does everyone obsess about Strep? These abscesses and most serious deep space neck infections are in fact caused by anaerobes.
I challenge the anonymous commenter's statement. The last time I checked the three most common organisms were Group A Strep, Other aerobic Strep, and Staph. Anaerobes are much less common.
Of course I would never know what this was but I was thinking meningitis too.
Interesting post Scalpel.
Great case!
Joints: I've only been practicing Head & Neck surgery for 25 years, so I guess my experience draining and culturing these counts for little. Remember too that anaerobes are exceedingly tough to culture out so that when you get loads of pus and a mixed bag of junk with no predominant organism you can pretty much guess that that awful odor is anaerobes. Oh and it very much depends on WHICH of the deep necks spaces you're talking about. Care to cite the studies you "last checked?"
Also, the problem with obsessing about Strep is that when the rapid test, cultures or the titers come back negative, people get lulled into a false sense of security. That is, they forget to look at the patient and concentrate on the lab result. That is exactly how so many deep space neck infections get to damned advanced at presentation.
BTW the inability of a child to rotate the head on the neck should be presumed to be from a Deep Neck infection in this clinical presentation. I'd be more worried about meningitis in a child who protested flexion extension maneuvers of the neck.
I'm glad you saved the little guy! Did you ever figure out what caused his abscess?
any port in a storm. good catch doc. rapid streps are worthless when you need 'em and don't matter when you don't.
Anonymous, here you go, dude:
1: Abdel-Haq NM, Harahsheh A, Asmar BL.
Retropharyngeal abscess in children: the emerging role of group A beta hemolytic
streptococcus.
South Med J. 2006 Sep;99(9):927-31.
2: Al-Sabah B, Bin Salleen H, Hagr A, Choi-Rosen J, Manoukian JJ, Tewfik TL.
Retropharyngeal abscess in children: 10-year study.
J Otolaryngol. 2004 Dec;33(6):352-5. Review.
3: Tan PT, Chang LY, Huang YC, Chiu CH, Wang CR, Lin TY.
Deep neck infections in children.
J Microbiol Immunol Infect. 2001 Dec;34(4):287-92.
4: Parhiscar A, Har-El G.
Deep neck abscess: a retrospective review of 210 cases.
Ann Otol Rhinol Laryngol. 2001 Nov;110(11):1051-4.
The patient was transferred to another facility that had Pediatric ENT coverage, so I don't have culture results or followup. I don't think the rapid strep test is helpful in the diagnosis of this condition, both because of the occasional time delay from the index illness to the development of abscess formation and the probability of overconfident early diagnostic closure that a positive rapid strep test would have prompted.
With a positive strep test, the patient would have probably been discharged with ineffective oral antibiotics without further studies. Scary.
To anonymous,
I'm also an ED doc. I've seen many many kids and adults who won't turn their heads side-to-side, but I've never diagnosed an retropharyngeal abscess.(nor missed any that I know of) That finding is not specific.
Scalpel, thanks for sharing this.
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