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“Facts are stubborn, but statistics
are more pliable.”
-- Mark Twain
Alan Chan, MD
Med-peds PGY4
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Chief Complaint: weakness
HPI: 46 yo Caus woman reports to the ER after “fall onto tailbone” a
couple days prior to presentation. Had presented initially after fall
and diagnosed with “back sprain” and sent home with supportive
care and pain medications. Now getting progressively weak, but
moreso over past day. Difficult to walk and brought in via EMS on
stretcher. Difficult to urinate (has to “push?”) and has not today yet.
Also developing subjective fever today. Severe pain and more
localized on neck area. Dysphagia and some odynophagia.
No chills, no N/V. Headache x couple times.
Some sore throat x couple weeks, non productive cough.
No dyspnea on exertion. No sick contacts.
No weight loss. LMP last week.
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Medications
• Flexeril 10 mg q8h prn pain
• Lortab 7.5/500 q6h prn
pain
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Allergies
NKDA
PMH: none
PSH: none
ROS: No chills, fatigue, night sweats.
No trauma, vision changes
No rhinorrhea, sneezing; No dyspnea on exertion,
edema, no shortness of breath, wheeze
No recent illness
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SH: Bookkeeper. 1 ppd x > 30 yr.
Occasional EtOH. Patient denies IVDU
FH: DM
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VS in ER: Temp 102.5, Resp 24, BP 115/61, Pulse
152. 94% on 4L NC
General: Alert female appears older than stated age
and in acute distress due to back pain.
HEENT: EOMI, PERRL, no scleral changes. OP
clear with no intact dentition, dry mucus
membranes. Red tongue.
Neck: soft, supple, no LAP but difficult due to pain.
Mild erythema along neck SCM.
Chest: CTA bilat, no wheezing; poor air entry effort
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CVS: tachy regular rhythm S1, S2, no murmur
Abd: BS +, non TTP.
No guarding.
Ext: no edema, 2+ pulses
Neuro: CN 2-12 intact, no tested deficits. 4/5
strength with intact reflexes at knee, elbow.
Decreased light touch per patient.
Skin: right antecubital area suspicious looking
Repeat exam by neurology a couple hours later.
CN 2-12 intact; DTRs 1+ in left, none in right. Plantar upgoing
bilat. Motor LUE 1/5, RUE 1+/5. UE bilat 1/5. lt touch intact.
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Differential Diagnosis
CC: back pain, weakness,
fever
HPI: 46 yo with
PMH:
none
Exam Findings
Several – fever,
appearance, mouth, neck,
tachy, declining neuro
findings
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Laboratory Data
CBC
BMP
Urinalysis
Cardiac Enzymes
Liver Function Tests
Coagulation
Endocrinology
Serology
Immunologic Studies
Other Serology
Body Fluid Analysis
Cytology
Pathology
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Microbiology
CXR
EKG
Ultrasound
CT Scan
MRI
Other Studies
Other Imaging
Clinical Course
Differential Diagnosis
Discussion
Please Press to Return
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CBC
12.2
194
13.5
35
Seg Neutro 85, Lymph 3, Mono 4
MCV 84 (80-99)
RDW 18.4 (<14.5)
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BMP
134
107
11
3.9
19
0.7
AG 8 (3-15)
Ca 6.5 (8.8-10.5)
Mg 1.5 (1.8-2.5)
PO4 xx (2.4-4.7)
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128
Urine Analysis
color
sp gr
pH
Hgb
ketone
glu
prot
LE
nitrite
urobil
bili
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yellow
1.025
5.5
mod
sm
neg
30
neg
neg
neg
neg
Microscopic
11-20 wbc
1-5 rbc
UDS (got APAP and dilaudid)
• Acetaminophen, opiates, THC, TCAa – pos
• Methamphetamines, Barbs, BDZs, Cocaine,
methadone, phencyclidine – neg
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Cardiac Enzymes
1st - TnI 0.12 (0.08-0.5 increased
risk); CK – MB 6.7 (0-6)
CPK - 699
BNP – 177
2nd – 0.47
3rd – 0.39
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Liver Function Tests
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AST
ALT
Alk Phos
Albumin
T Bilirubin
D Bilirubin
Protein
65 (15-41)
73 (7-35)
65 (32-91)
2.5 (3.5-4.8)
1.3 (0.3-1.2)
xx (0.1-0.5)
5.6 (6.1-7.9)
Lipase
< 10 (18-51)
Coagulation
PTT
PT
INR
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24.5 (21-33)
11.4 (10.3-13.0)
1.0
Endocrinology
TSH
Free T4
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X (0.34-5.6)
X (0.6-1.6)
Serology
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HEPATITIS B SURFACE ANTIGEN Non-reactive
HEP B CORE ANTIBODY IGM Non-reactive
HEPATITIS A IGM Non-reactive
HEPATITIS C ANTIBODY Reactive !
Genotype 3
Studies from abscess fluid
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Cytology
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Other Serology
• Inflammatory markers – would have been very
elevated
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Body Fluid Analysis
• AFB neg
• X2
• Fungal neg
• Mycology neg
• MRSA tissue
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Microbiology
• UCx neg
• BCx GPC
MRSA!!
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Chest
X-ray
0755 8/20 FINDINGS:
Lungs: Low lung volume. Bilateral lower lobe subsegmental atelectasis. Multifocal bilateral
nodular and masslike consolidations predominantly in the lung periphery with a dominant
lesion in the right upper lung zone. The etiology of these findings is indeterminate.
Multicentric primary pulmonary neoplasia should also be considered.
Multifocal pulmonary infection including septic emboli and opportunistic infections cannot be
excluded.
Pleura: Small bilateral pleural effusions. No pneumothorax.
Heart and Mediastinum: Cardiomegaly. Tortuosity of the thoracic aorta.
Abnormal contour of the mediastinum consistent with mediastinal lymphadenopathy.
IMPRESSION:
1. Low lung volumes. Basilar atelectasis.
2. Multifocal nodular and masslike consolidations as described above. The differential
diagnosis includes multicentric neoplasia (including metastatic disease) and multicentric
infection (including septic emboli).
3. Small bilateral pleural effusions.
4. Mediastinal lymphadenopathy.
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HR 143, PR 128, QTc 414
Sinus tachycardia
Probable left atrial abnormality
Borderline low voltage in frontal leads
RSR’ pattern in V1 or V2, right RVH
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CT neck soft tissue
IMPRESSION:
1. Soft tissue swelling of the retropharyngeal and perivertebral space,
and thickening of right sternocleidomastoid muscle with induration of
surrounding fat, likely cellulitis versus phlegmon. There is thickening
of the right sternocleidomastoid muscle, and induration of the
surrounding fat, which could indicate early inflammatory changes.
There is focal collection of fluid in the retropharengeal space and
around the posterior muscles. It is unclear which space the fluid is in or
whether some of it is phlegmon.
2. Right apical lung infiltration, most likely septic emboli.
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MRI – C - SPINE without contrast
• Impression:
• Degenerative changes of the cervical spine with disk protrusions
at the C4-5, C5-6, C6-7 levels. This appears to displace but
does not appear to compress the spinal cord. There is extensive
edema throughout the soft tissues of the neck posteriorly. There
is prevertebral soft tissue swelling. In the setting of trauma this
may represent extensive muscle injury and prevertebral swelling.
In the setting of infection this may represent phlegmon or
abscess formation withint the soft tissues. Slightly enlarged
upper and mid cervical portion of the spinal cord with possible
cord edema. Possibility of prevertebral and paraspinous
abscess. Recommend contrasted study.
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2-D Echocardiogram
CONCLUSIONS:
Normal left ventricular systolic function, with an
estimated ejection fraction of 60%.
Normal right ventricular dimensions and systolic
function.
No significant valvular abnormalities including
vegetation.
Normal pulmonary artery systolic pressure of 27 mm Hg.
No pericardial effusion.
No previous study available for comparison.
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Other Imaging
• MRI L and T spine done after emergent OR
• Postsurgical changes at the cervicothoracic junction
with incompletely evaluated marked soft tissue
abnormality in the posterior paravertebral soft
tissues. There is effacement of the cervicothoracic
spinal cord with edematous changes and
effacement of the CSF space.
• No acute abnormality of the lumbar spine for
enhanced MRI. No drainable fluid collection.
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Clinical Course
• Given 10 mg IV of decadron in the ER, 3L of NS
bolus
• Taken to the OR by Neurosurg
• C3-T2 laminectomy and evacuation of epidural
abscess
• Positive BCx x 4 sets, none after 5 days of
antibiotics, but persistently febrile.
• Dx of spinal epidural abscess and Lemierre’s
syndrome.
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Discussion - Goals
• Overview of spinal epidural abscess (much more
common than intracranial), retropharyngeal abscess
(and other deep neck infections), Lemierre’s
syndrome (postanginal sepsis syndrome)
• Presentation, dx, and tx of each.
MKSAP Q?
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Overview – spinal epidural abscess
• Doubled over past decades to 1 in 10000 hospital
admits.
• Risk factors include age, spinal instrumentation, IV
drug use.
• Comorbid medical conditions – DM, alcoholism, HIV,
spinal abnormality, trauma, tattooing, local or
systemic infection source
• Bacterial spread via contiguous or hematogenous
dissemination.
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Pathogens
• Staph aureus – 2/3 cases since from skin flora
• Staph epidermidis (post op from spinal procedures,
glucocorticoid injections, catheters)
• Gram negative - E. coli, Pseudomonas
• Rarely – anaerobic, mycobacteria, fungi, parasites
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Complications
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Endocarditis
Vertebral osteomyelitis
Psoas muscle abscess
Epidural infection leading to cord injury by
compression or vascular occlusion from septic
thrombophlebitis.
Presentation and Staging system
• Triad of back pain, fever, and neurologic deficits
rarely present – except in our patient!
• Stage 1 – back pain at level of affected spine
• Stage 2 – nerve root pain radiating from affected
spine
• Stage 3 – motor weakness, sensory deficits, bladder
+/- bowel dysfunction
• Stage 4 - paralysis
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Diagnosis
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Clinical findings with labs and imaging
Leukocytosis in 2/3, elevated inflammatory markers
Bacteremia in about 2/3 as well, moreso in S. aureus
Lumbar puncture is not routinely recommended unless
myelography is done. Slight risk of meningitis or
subdural infection if needle crosses the epidural
abscess. Little additional info gained.
• MRI recommended
• Commonly misdiagnosed given nonspecific features on
initial presentation.
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XR – L3-4 narrowing
CT – bony erosion of L3
and L4
Bone scan – inc
technetium uptake
MRI – abscess a/w
osteomyelitis and
diskitis
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Treatment
• Glucocorticoids to help swelling until surgery.
• Surgery – decompressive laminectomy and incision and
drainage and systemic antibiotics +/- removal of any
implanted devices.
• ABX – vanc, metro, cephalosporin 3rd or 4th gen x > 6 wk
• Non surgical considerations – if patients refuses, high
operative risk, paralysis over 24-36 hr, panspinal infection.
BUT, may still require drainage and to control sepsis.
• Preoperative neurologic stage is most important predictor of
final neurologic outcome.
• 5% mortality
• Final neurologic outcome assessed at least 1 year out.
• MRI in 4-6 wk or if clinical deterioration.
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Neck space infections
• Danger space is
formed anteriorly by the
alar fascia and
posteriorly by the
prevertebral fascia
• Prevertebral space
continues to psoas
muscle
• Can allow
retropharyngeal
infections to spread to
mediastinum.
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Quinsy aka peritonsillar abscess
• All ages, but more in 15-30 years old
• suppurative complication of acute tonsillitis with
extension into the peritonsillar space.
• Ill appearance with fever, sore throat, dysphagia,
trismus (can’t open mouth), drooling, muffled voice
• Usu GAS, occasional beta hemolytic strep, H flu, s
aureus, anaerobes (unasys)
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Parotits
• Usually in more elderly population
• Usu firm erythema with swelling of auricular areas.
• Polymicrobial – S aureus and anaerobic; gram neg
in hospitalized patients
• OR viral – typically more prodromal period and
bilaterally.
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Submandibular space - Ludwig’s angina
• Bilateral, BOTH submandibular and sublingual spaces,
rapidly spreading cellulitis WITHOUT abscess or lymph
involvment
• 70-85% of cases follow infection of mandibular molar
teeth
• Can see enlarged tongue
• Mouth pain, stiff neck, drooling, dysphagia. Symmetric
swelling
• Tx – AIRWAY!! – and also abx like unasys
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Lemierre’s syndrome aka postanginal sepsis
aka suppurative jugular thrombophlebitis
• Venous thrombosis a/w inflammation in the setting of
bacteremia
• Usually preceded by pharyngitis or oropharyngeal
infection.
• Neck pain worse with turning away from involved
side.
• Dysphonia, dysphagia
• Possible swelling and induration
• Clinical manifestation of septic pulm emboli,
persistent fevers despite antibiotics
• Bugs – anaerobic like Bacteroides, or
Fusobacterium
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Hx and Tx
• Described in 1936 with series of throat infections
with anaerobic septicemia.
• Increasing incidence, maybe by more reporting,
increased antibiotic resistance, or better imaging
studies.
• Fusobacterium has had more PCN resistance.
• Typically seen in previously healthy young adults.
• Distant emboli from septic thrombophlebitis from
jugular vein thrombosis – lungs, joints commonly
affected.
• Role of anticoagulation is controversal as segment
of affected vessel is short.
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Question of the Day
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40 yo retired public health nurse with a 2 yr hx of rapidly progressive
rheumatoid arthritis is evaluated prior to etanercept (enbrel). diclofenac,
methotrexate, and prednisone all did NOT work. She had been in good
health before developing rheumatoid arthritis.
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PE is normal except for changes related to rheumatoid arthritis. CBC
shows mild normochromic, normocytic anemia with normal leukocyte and
platelet counts. A recent CXR was normal.
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Which of the following tests would be most appropriate before starting
therapy with etanercept?
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A Nitroblue tetrazolium dye test
B Measurement of quantitative serum immunoglobulins
C Skin testing with mumps and Candida antigens
D Tuberculin skin testing
E Measurement of total hemolytic complement level (CH50)
• D – TB skin test - this and other anti–tumor necrosis factor-α
agents (e.g., infliximab/remicade and adalimumab/humira) are
at higher risk for developing latent TB.
• Patients with latent TB who do develop reactivation TB tend to
present with extrapulmonary disease, and a quarter have
disseminated disease. Active TB occurs within 12 weeks of
beginning therapy with infliximab, 30 weeks of beginning
therapy with adalimumab, and 46 weeks of beginning therapy
with etanercept. Patients who have a positive screening test for
latent TB should start isoniazid.
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• CGD – def neutrophil fxn – check NBT dye test.
• No humoral immunity – pulm inf’n, bacteremia, meningitis –
check QuIgs
• No cellular immunity – viral, fungi, intracell bugs – check TST,
and mumps and candida antigen challenge
• Terminal complement def – disseminated gonococcal or
Neisseria meningitis – check CH50
• Even 5-10 mg pred increases inf’n a/w Cell medi immunity!!
Patients taking anti–TNF-α
inhibitors are at increased risk for
developing latent TB.
Patients about to begin therapy with
anti–TNF-α inhibitors should
undergo TST screening.
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References
• MKSAP 14
• Uptodate.com “Deep neck space infections”. Accessed
9/26/2010.
• Emedicine article. “Retropharyngeal Abscess”,
http://emedicine.medscape.com/article/995851-overview.
Acessed 9/26/2010.
• Darouiche, RO. Spinal Epidural Abscess. N Engl J Med 2006;
355: 2012-20.
• Karkos RD, et al. Lemierre’s Syndrome: A Systematic Review.
Laryngoscope 2009; 119: 1552-59.
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