Tuberculosis (TB) is the commonest infection in a developing country like India. One of the many presentations of TB is meningitis, but tubercular retropharyngeal abscess is a very rare presentation of TB. A retropharyngeal abscess is an immediate life-threatening emergency, with potential airway compromise and other catastrophic complications including compressive myelopathy. We report clinical, radiological and histological findings in a symptomatic 17-year-old female who presented with quadriparesis due to cervical compressive myelopathy due to tubercular retropharyngeal abscess with tuberculous meningitis.
Keywords: Tubercular retropharyngeal abscess, tuberculous meningitis, compressive high cervical myelopathy
India is the country with highest burden of tuberculosis (TB). The World Health Organization (WHO) statistics of 2015 give estimated incidence of 2.2 million cases of TB in India out of global incidence of 9.6 million cases. TB most commonly involves lungs. Common sites of extrapulmonary TB are lymph nodes, osteoarticular areas, abdominal organs and central nervous system. In view of its unusual presentation, diagnosis of extrapulmonary can be difficult and high index of suspicion is required. Though tuberculous meningitis is common, its association with tubercular retropharyngeal abscess is rare. Again, tubercular retropharyngeal abscess are mainly secondary to TB spine due to spread of infection hematogenously via Batson’s plexus. Here we want to draw attention to a rare presentation of TB as tuberculous meningitis with tubercular retropharyngeal abscess causing compressive cervical myelopathy and nontraumatic atlanto-axial dislocation. Chronic tubercular retropharyngeal abscess is rare in immunocompetent adults, especially without spine involvement. Tubercular retropharyngeal abscess requires prompt diagnosis and early management, which frequently involves surgical drainage with antibiotics and antitubercular treatment.
A 17-year-old, right-handed female came with complaints of weight loss since 2 months. Patient also had headache since 2 months, which was mostly localized in character to posterior part. There was history of low-grade, on and off fever, with no diurnal variation since 2 months. Patient developed neck pain for 1 month which was gradual in progression and developed painful restricted neck movements since few days. Patient consulted local doctors for the same complaints and had received symptomatic treatment. Patient developed sudden onset of right-sided hand weakness while doing her routine activities since 7 days followed by left leg stiffness while walking since 7 days. She was brought to the hospital where she was admitted. Basic investigation was done including CT scan of brain, which was normal. She developed all four-limb weakness followed by breathlessness since 2 days and developed sudden onset of altered sensorium since 1 day and hence was referred to higher center for further management.
Patient was evaluated and investigated. There was no history of cough, hemoptysis, chest pain, foreign body impaction, ear discharge, odynophagia, dental extraction, vomiting or convulsions. There was no history of TB in past. On clinical examination, there were no signs of anemia, jaundice, cyanosis or clubbing. Vitals were stable with pulse - 72 /min, blood pressure - 122/70 mmHg and respiratory rate - 16 cycles/min. There was no bony tenderness or swelling in cervical spine but the neck movements were painful and restricted. Nervous system examination revealed that the patient was rousable. There was no cranial nerve involvement. Tone was increased in all four limbs. Deep tendon reflexes were exaggerated in all four limbs. Ankle clonus and Babinski’s sign were positive; power was 2/5 in all four limbs. Examination of cardiovascular and respiratory system did not show any abnormality.
On investigation, hemoglobin was 11.2 g/dL and white blood cell (WBC) count was 11, 500/mm3. Renal function tests and liver function tests were within normal limits. Erythrocyte sedimentation rate (ESR) was 102 mm 1st hour. Chest X-ray was suggestive of normal findings. Ultrasonography (USG) abdomen was done and findings were within normal limits. Fundoscopic examination of bilateral eyes was normal. Patient’s X-ray neck was done and was suggestive of atlanto-axial dislocation (Fig. 1). Lumbar puncture was done after taking valid consent and was suggestive of neutrophilic predominance but raised adenosine deaminase (ADA) level. Patient was started on CAT 1 AKT. Magnetic resonance imaging (MRI) brain with cervical spine screening was done and was suggestive of large retropharyngeal abscess compressing corticomedullary junction and from C1 to C3 level with significant cord edema (Fig. 2). ENT Surgeon and Neurosurgeons were consulted and transoral incision and drainage of retropharyngeal abscess was done. Patient was tracheostomized in view of respiratory failure due to diaphragmatic involvement and was kept on ventilatory support in intensive care unit (ICU). No surgical intervention could be done for spine stabilization and patient’s neck was immobilized with hard cervical collar as a conservative management. Pus was examined for routine microscopy and was found to have lymphocytic predominance. GeneXpert for pus aspirated from retropharyngeal abscess showed Mycobacterium tuberculosis (MTB) and hence diagnosis of tubercular retropharyngeal abscess was established.
Figure 1. X-ray cervical spine suggestive of atlanto-axial dislocation.
Figure 2. T2-weighted MRI cervical spine suggestive of large retropharyngeal abscess compressing corticomedullary junction and cervical cord.
Patient was continued on CAT 1 AKT as GeneXpert for MTB was done and no rifampicin resistance was detected. Pus culture for MTB was negative. Patient regained consciousness within 3 days of starting antitubercular therapy. Patient developed ventilator-associated pneumonia and started on higher antibiotics accordingly tracheal culture sensitivity report. But in spite of all measurements patient could not be survived and died due to sepsis and shock.
A retropharyngeal abscess in an infection in one of the deep spaces of neck. An abscess in this location is an immediate life-threatening emergency, with potential for airway compromise and other catastrophic complications. Complications of retropharyngeal abscess are secondary to mass effect, rupture of abscess or spread of infection. The rupture of abscess can cause aspiration of pus, resulting in asphyxia or pneumonia. Infection can spread, resulting in inflammation and destruction of adjacent tissue. Posterior spread of infection can result in osteomyelitis, and erosion of spinal column causing subluxation or dislocation as in our case where she developed atlanto-axial dislocation due to posterior spread of abscess. Chronic retropharyngeal abscess occurs in adults and cause is almost always TB. Retropharyngeal TB is a rare presentation of extrapulmonary TB and its association with tuberculous meningitis in absence of pulmonary involvement is very rare. Retropharyngeal abscess in adults is usually secondary to tubercular involvement of cervical spine. Symptoms in adults are sore throat, fever, odynophagia, neck pain and dyspnea as in our case. Route of spread of TB could be due to retropharyngeal space, via lymphatics, to persistent retropharyngeal lymph node. A hematogenous spread can also occur from pulmonary TB or from any other site.
The diagnosis of tubercular retropharyngeal abscess is based on careful patient history and examination along with a high index of clinical suspicion.
The diagnosis of retropharyngeal abscess is further supported by radiological imaging, which plays an important role in assessing extent of disease and possible damage to important structures, such as cervical spine. A CT scan accurately differentiates cellulitis from abscess with accuracy of 89%. MRI provides a better delineation of soft tissues in the neck and is very useful in assessing vascular complications such as internal jugular vein thrombosis. Pathophysiology explained for atlanto-axial dislocation may be inflammatory ligamentous laxity of transverse ligament and atlanto-axial joint. No single report has been reported in Indian patients with nontraumatic atlanto-axial dislocation due to tubercular retropharyngeal abscess without pulmonary involvement as per best of our knowledge.
In a case of tubercular retropharyngeal abscess with neurological complications, recovery does occur following prompt drainage and antitubercular therapy. In our case, trans-oral drainage of abscess was done and decompression was achieved.
As in any abscess, mainstay of treatment of tubercular retropharyngeal abscess is drainage of pus. Surgical drainage of pus through oral, cervical or combined oral and cervical route has been described. Therapeutic ultrasound-guided aspiration has been used successfully and can be repeated if necessary. The standard recommended regimen is 6 months of isoniazid and rifampicin, supplemented in the first 2 months with pyrazinamide and ethambutol for pulmonary TB. For extrapulmonary TB including bone involvement recommended duration of antitubercular medication is 9-12 months.
- Global Tuberculosis Control 2015, WHO, Geneva, 2015. Available at: www.who.int/tb/publications/global_report.
- Singh J, Velankar H, Shinde D, Chordia N, Budhwani S. Retropharyngeal cold abscess without Pott’s spine. S Afr J Surg. 2012;50(4):137-9.
- Marques PM, Spratley JE, Leal LM, Cardoso E, Santos M. Parapharyngeal abscess in children: five year retrospective study. Braz J Otorhinolaryngol. 2009;75(6):826-30.
- Wong KK, Fang CX, Tam PK. Selective upper endoscopy for foreign body ingestion in children: an evaluation of management protocol after 282 cases. J Pediatr Surg. 2006;41(12):2016-8.
- Harkani A, Hassani R, Ziad T, Aderdour L, Nouri H, Rochdi Y, et al. Retropharyngeal abscess in adults: five case reports and review of the literature. Scientific World Journal. 2011;11:1623-9.
- Moghtaderi A, Alavi-Naini R, Rashki S. Cranial nerve palsy as a factor to differentiate tuberculous meningitis from acute bacterial meningitis. Acta Med Iran. 2013;51(2):113-8.
- Berger TJ. Retropharyngeal abscess. Available at: www.eMedicine.com.
- Meher R, Agarwal S, Singh I. Tuberculous retropharyngeal abscess in an HIV patient. Hong Kong Med J. 2006;12(6):483-5.
- Colmenero JD, Jiménez-Mejías ME, Reguera JM, Palomino-Nicás J, Ruiz-Mesa JD, Márquez-Rivas J, et al. Tuberculous vertebral osteomyelitis in the new millennium: still a diagnostic and therapeutic challenge. Eur J Clin Microbiol Infect Dis. 2004;23(6):477-83.
- Miller WD, Furst IM, Sàndor GK, Keller MA. A prospective, blinded comparison of clinical examination and computed tomography in deep neck infections. Laryngoscope. 1999;109(11):1873-9.
- Gidley PW, Ghorayeb BY, Stiernberg CM. Contemporary management of deep neck space infections. Otolaryngol Head Neck Surg. 1997;116(1):16-22.
- Schuler PJ, Cohnen M, Greve J, Plettenberg C, Chereath J, Bas M, et al. Surgical management of retropharyngeal abscesses. Acta Otolaryngol. 2009;129(11):1274-9.
- Nalini B, Vinayak S. Tuberculosis in ear, nose, and throat practice: its presentation and diagnosis. Am J Otolaryngol. 2006;27(1):39-45.
- Treatment of tuberculosis: guidelines. 4th Edition, WHO/HTM/TB2009.420:95.
- Robertson S, Pinstein ML, LaVelle DG. Non-traumatic atlantoaxial subluxation in an adult secondary to retropharyngeal abscess. Orthopedics. 1987;10(11):1545-7.