A previously healthy 2-year-old boy was hospitalized after 2 weeks of persistent fever (temperature to a maximum of 38.9°C [102°F]) and a 2-day history of neck stiffness. There was no history of cough, rhinorrhea, or dysphagia. The oropharynx could not be examined because of neck stiffness. The patient had bilateral anterior cervical lymphadenopathy. Blood cultures grew group A streptococcus, and a pharyngeal swab(using a rapid test) was positive for group A streptococcus antigen. The cerebrospinal fluid profile was normal. MRI scans of the patient’s neck showed a retropharyngeal phlegmon—a spreading, diffuse inflammatory reaction to infection that extends into deepsubmucous tissues and muscles and creates multiple small pockets of pus without true abscess formation. The patient was treated with intravenous ceftriaxone and clindamycin for 7 days. These antibiotics were selected initially for their broad-spectrum coverage of infections related to the oropharynx. After consultation with a pediatric infectious disease specialist, however, the antibiotics were discontinued because of concerns about possible infection with other bacteria that had not been detected by culture and rapid tests. As the patient’s fever resolved, his range of neck movement increased and his appetite and activity level improved. He was discharged home, where intravenous clindamycin therapy was to be continued for 4 weeks. This length of therapy was based on the prehospital course and extent of the phlegmon. The patient’s health continued to improve over the next week. However, 4 days before he was readmitted, he became irritable and lethargic. He began to refuse to rotate his neck and was increasingly fatigued. His mother noticed that he was holding his head to one side. According to a home health agent, the patient had apparently been receiving the antibiotic as prescribed. On the day before readmission, the patient continued to show signs of fatigue and neck pain. His parents noted that while riding in their car, the patient held his neck with both hands—especially when the ride became bumpy. The patient had been afebrile since his discharge: there was no vomiting, diarrhea, cough, nasal congestion, or voice changes. On readmission, the patient was afebrile and had normal vital signs. He was irritable, however, and lay in bed with his head tilted to the left. His oropharynx was not erythematous; the uvula was in the midline and there was no tonsillar hypertrophy. The patient was reluctant to move his neck in any direction, but especially side-to-side. There were no other notable physical findings. Results of initial laboratory studies were as follows: white blood cell count, 8870/μL (normal, 6200 to 14,500/μL), with 61% neutrophils, 32% lymphocytes, and 7% monocytes; C-reactive protein level, 1.6 mg/dL (normal, 0 to 0.7 mg/dL); and erythrocyte sedimentation rate, 75 mm/h (normal, 10 to 15 mm/h). A repeated blood culture was not performed because the patient was afebrile. Serum electrolyte levels were normal. A lateral cervical spine radiograph showed subluxation (Figure 1). CT scans with contrast revealed marked anterior subluxation of C1 on C2 measuring 1 cm (Figure 2). Thickening of the retropharyngeal soft tissues with an unchanged area of phlegmon was also noted. These findings were confirmed by MRI. What’s Your Diagnosis?
Posted on: Sun, 04 Jan 2015 13:50:14 +0000
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