This week’s Med Student case of the week brought to you by Joe Skopek…
Pt is a 6 y.o. child brought to the ED for eval of fever and neck pain that was noted when he awakened about 6am after going to bed asymptomatic. The patient was febrile to 104 and given tylenol which did bring the fever down to about 100. The child has progressively wanted to move the head less over the course of the day. Swallowing is becoming more painful. No nausea or vomiting, no rash. Mom denies any known sick contacts and reports imms are up to date.
So. Fever. Stiff neck. We can see where this is going yes? We’re missing any mention of headache though. It’d be worth asking about light sensitivity as well.
Further questioning finds the child cried when offered water earlier and mom now reports child is becoming hoarse.
Remember, a differential is never just one thing and rarely just one organ system.
Presenting vitals are significant for a temp of 103, HR 130, RR 20, BP 132/68, and 97%ra sat.
Clearly febrile, and somewhat tachycardic. The Blood Pressure is actually too high and should be repeated once he’s no longer crying or with an appropriate cuff size.
The child appears ill-appearing. Exam of the oropharynx demonstrates reduced rotation and flexion of neck due to pain. He is tender to palpation of the throat. Brudzinski testing was reported as positive, Kernig’s negative.
Remember, Brudzinski’s sign is where the patient flexes at the hips and knees in response to passive flexion of the neck. In Kernigs testing the patient’s hip and knee is bent and then with the hip still flexed the knee is extended testing for pain. Neither are particularly sensitive or specific for meningitis.
So to summarize so far, we have a patient with sore throat, neck stiffness, fever, but without really significant headache. Certainly meningitis is a consideration, but the overall picture was actually better for a primary problem of the throat/neck and so labs and a soft-tissue neck x-ray were obtained with the plan for LP if the x-ray was negative.
In addition, I generally recommend that if I’m worried enough to do a spinal tap I’m probably going to start IV antibiotics as early as possible as well.
CBC was reported at 20 (remember to also look at the differential whether the total count is elevated or not) with an ESR of 47 and CRP of 5.8. Blood cultures were sent as well. This is the soft tissue neck:
So. Most of us remember the 6 at 2, 22 at 6 rule for adults (6mm of soft tissue is allowable in front of C2, 22mm of soft tissue is allowable in front of C6), but what do we do with a kid? Grossly we can see that the soft tissue is greater in front of C2 than C6. Well, per a study by Vermess et al (1), we would expect about 7mm in front of C2 and about 11mm at C6. Given that we know there’s more density in front of C2 than C6 in our patient, there’s an abnormality there. It’s an interesting reflection of the differences in adult and pediatric proportions that a child has about the same absolute amount of soft tissue density in front of C2 as an adult.
CT showed extensive retropharyngeal fluid/edema compatible with inflammation or infection but no discrete abscess. The child was treated with decadron, tylenol, saline, IV clindamycin, and admitted to pediatrics.
To me the take-home this case reiterates is that retropharyngeal abscess (or developing retropharyngeal abscess) can look a lot like meningitis.
Vermess D, Rojas CA, Shaheen F, Roy P, Martinez CR. Normal pediatric prevertebral soft-tissue thickness on MDCT. Am J Roentgenol. 2012 Jul; 199(1):W130-3.