Clivus Osteomyelitis as a Complication of Retropharyngeal Abscess in an Immunocompetent Adolescent
Makaleler > Tam Makale · 2024
Yazarlar: Coskun Ekemen, Gülhadiye AVCU, Asli Arslan, Emine Cigdem Ozer, Cenk ERASLAN, Hasan TANRIVERDİ O, Zümrüt ŞAHBUDAK BAL
Pediatric Infectious Disease Journal, Uluslararası, Scopus, 2024, cilt 43, ss e116-e117
DOI: 10.1097/inf.0000000000004205
Özet
To the Editors: The retropharyngeal space is a longitudinal space that spans from the base of the skull to the mediastinum at the level of the second thoracic vertebra.1 Infections in these areas can lead to lymphadenitis, progressing from cellulitis to organized phlegmon and retropharyngeal abscess (RPA).2 Untreated or inadequately treated RPA can rupture, facilitated by firm palpation and cervical manipulation, potentially spreading to the pharynx and larynx and may lead to infection in the skull base and prevertebral fascia. Here, we present a case of clivus osteomyelitis as a complication of RPA in a previously healthy 17-year-old boy. A 17-year-old male patient presented with a 2-week history of throat, neck and head pain, along with difficulty swallowing and a fever lasting for 5 days. The patient reported irregular use of amoxicillin-clavulanic acid, neck massage and cervical traction for his severe neck pain during this period. He was previously healthy without any hospitalization and had a history of smoking for 4 pack years with poor oral hygiene. Physical examination revealed hyperemic tonsils and oropharynx, tenderness on neck palpation and neck movements were painful without any fluctuating mass. Laboratory tests revealed normal acute phase reactants (C-reactive protein: 2 mg/L, procalcitonin: <0.06 µg/L and total leukocyte count: 13.5 × 103/μL). Magnetic resonance imaging (MRI) revealed a multiloculated appearance with contrast enhancement, extending bilaterally within the prevertebral muscle planes from the midline superiorly to the skull base and clivus, with a cranio-caudal diameter of approximately 1.5 cm and a maximum transverse diameter of 4 cm (Fig. 1). Intravenous vancomycin (60 mg/kg/d), metronidazole (30 mg/kg/d) and cefotaxime (300 mg/kg/d) was initiated. Abscess drainage was performed on day 2. No growth was detected in the throat swab, blood and abscess cultures. The patient received a total of 28 days of intravenous antibiotic therapy, consisting of 21 days of cefotaxime, vancomycin and metronidazole, followed by 7 days of cefotaxime and clindamycin. A significant clinical improvement was achieved. He was followed up with a neck brace, and treatment was completed in 8 weeks with oral ciprofloxacin and clindamycin. Control MRIs showed a gradual regression of abscess and osteomyelitis findings. Clivus osteomyelitis is a rare condition and usually occurs when the infection spreads directly from the paranasal sinuses or adjacent skull base bones.3 Besides, untreated or inadequately treated RPA can lead to rupture, facilitated by firm palpation and sudden neck movements, potentially causing infection in the skull base and prevertebral area. In the differential diagnosis, the possibility of a metastatic malignancy should be considered.4 Drainage of the abscess and stabilization of the cervical spine are crucial in these patients. Due to its polymicrobial nature, parenteral administration of broad-spectrum antibiotic therapy against both aerobic and anaerobic microorganisms is essential. MRI provides superior soft tissue evaluation than both ultrasonography and tomography, allowing a more precise differentiation of abscess from cellulitis or lymphadenomegaly.5 In summary, we present a case of clivus osteomyelitis, a rare complication of RPA, which was successfully treated with prompt medical and surgical intervention. The patient’s history of irregular outpatient antibiotic use and the fact that the abscess drainage was performed 2 days after broad-spectrum antibiotic therapy initiation may have contributed to our failure to isolate the causative agent.FIGURE 1.: A: MRI T2 sagittal section before treatment. Black arrow indicates adenoid vegetation, notched black arrow indicates clivus osteomyelitis, white arrows indicate abscess in the retropharyngeal region. B: MRI T2 sagittal section after treatment. The notched black arrow indicates the regression of adenoid vegetation, and the black arrow indicates the regression of clivus osteomyelitis. No abscess was observed in the retropharyngeal region indicated by white arrows.