A 4-year-old boy is brought to the emergency department with fever and neck pain. He has had rhinorrhea, nasal congestion, and a sore throat for the past week. Two days ago, he developed fever and worsening neck pain. Today, the patient has refused to eat or drink. He has no chronic medical conditions and immunizations are current. Temperature is 39.7 C (103.5 F), pulse is 120/min, and respirations are 24/min. On examination, the patient appears tired and uncomfortable. Palpation of the neck reveals bilateral anterior cervical lymphadenopathy. The patient refuses to move his neck; passive extension is painful. His voice is muffled. Mouth opening is limited by pain, and the tonsils appear erythematous and symmetrically enlarged with gray exudates. The uvula is midline. Chest auscultation reveals good bilateral air entry without stridor or rhonchi. Lateral neck radiograph shows widened prevertebral space but no other abnormalities. Which of the following is the most likely diagnosis in this patient?

Question

A 4-year-old boy is brought to the emergency department with fever and neck pain.  He has had rhinorrhea, nasal congestion, and a sore throat for the past week.  Two days ago, he developed fever and worsening neck pain.  Today, the patient has refused to eat or drink.  He has no chronic medical conditions and immunizations are current.  Temperature is 39.7 C (103.5 F), pulse is 120/min, and respirations are 24/min.  On examination, the patient appears tired and uncomfortable.  Palpation of the neck reveals bilateral anterior cervical lymphadenopathy.  The patient refuses to move his neck; passive extension is painful.  His voice is muffled.  Mouth opening is limited by pain, and the tonsils appear erythematous and symmetrically enlarged with gray exudates.  The uvula is midline.  Chest auscultation reveals good bilateral air entry without stridor or rhonchi.  Lateral neck radiograph shows widened prevertebral space but no other abnormalities.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d6cd_2cdc_bc81_4797b32bc3b4_MD0003_00 This patient's fever, odynophagia/dysphagia, neck pain with extension, muffled voice, and x-ray findings are concerning for retropharyngeal abscess (RPA). RPA is a soft-tissue infection of the neck due to bacterial (most commonly Streptococcus pyogenes, Staphylococcus aureus, or oral anaerobes) infection of the potential space between the pharynx and the vertebral fascia. It is most often preceded by upper respiratory infection, as in this case, but can also result from direct spread of local bacterial infection (eg, pharyngitis, tonsillitis). RPA occurs most commonly in children age 6 months to 6 years. The incidence decreases after age 6 years due to retropharyngeal lymph node regression and fewer viral upper respiratory infections. On lateral neck x-ray, the prevertebral soft-tissue space normally is narrower than the vertebral bodies; widening of this prevertebral space is suggestive of RPA. A CT scan with contrast confirms the diagnosis. Large RPAs can obstruct the airway and major vascular structures. Early diagnosis, prompt antimicrobial therapy, and surgical drainage for larger abscesses are essential to prevent obstructive complications. (Choice A) Diphtheria is rare in developed countries due to widespread vaccination. It presents with gray-colored tonsillar pseudomembrane and can cause airway obstruction. Diphtheria is unlikely in this immunized child. (Choice B) Epiglottitis presents with a high fever, drooling, and stridor that can progress rapidly to life-threatening airway obstruction. Lateral x-ray shows a swollen epiglottis ("thumb sign"), which is not present in this child. Lateral x-ray (Choice C) Meningitis presents with fever, neck stiffness/pain, headache, and photophobia. Neck flexion is painful due to stretching of the inflamed meninges; extension usually brings relief. This child has pain with extension, and the absence of headache and photophobia makes meningitis unlikely. (Choice D) Peritonsillar abscess can also cause fever, muffled voice, and throat pain. Significant tonsillar swelling can cause uvular deviation to the contralateral tonsillar pillar. This child has no tonsillar mass or uvular deviation. Peritonsillar abscess (Choice F) Tracheitis is caused by bacterial superinfection of the trachea following upper respiratory tract infection and presents with severe croup-like symptoms, including fever and stridor. Neck x-rays may show tracheal narrowing. This child has no stridor or tracheal narrowing on x-ray. tracheal narrowing Educational objective: Retropharyngeal abscess in children presents with fever, dysphagia, muffled voice, and pain with neck extension. Lateral neck soft-tissue x-rays will show a widened prevertebral space. References: Retropharyngeal abscess: diagnosis and treatment update. (http://www.ncbi.nlm.nih.gov/pubmed/22338591) Retropharyngeal and prevertebral spaces: anatomic imaging and diagnosis. (http://www.ncbi.nlm.nih.gov/pubmed/23153750)

A 4-Year-Old Boy Is Brought to the Emergency Department with Fever