A case of cervical Pott\'s disease revealed by parapharyngeal abscess

Share Embed


Descrição do Produto

European Annals of Otorhinolaryngology, Head and Neck diseases (2011) 128, 151—153

CASE REPORT

A case of cervical Pott’s disease revealed by parapharyngeal abscess E.S. Diom a,c,∗, C. Ndiaye a, A.B. Djafarou a, I.C. Ndiaye a, P.M. Faye b, A. Tall a, M. Ndiaye a, B.K. Diallo a, R. Diouf a, E.M. Diop a a

Service d’ORL et chirurgie cervico-faciale, centre hospitalier national universitaire de Fann, avenue Cheikh Anta Diop, BP 5035, Dakar, Senegal b Service de pédiatrie, centre hospitalier national universitaire de Fann, avenue Cheikh Anta Diop, BP 5035, Dakar, Senegal c BP 23656 Dakar Ponty, Senegal Available online 9 March 2011

KEYWORDS Pott’s disease; Retrostyloid abscess; Tuberculosis

Summary Introduction: We report a case of cervical Pott’s disease revealed by parapharyngeal abscess. Case report: A seven-year-old boy was admitted with a three-week history of painful fluctuating left lateral cervical swelling, associated with night sweats. Examination found trismus, through which a lateral pharyngeal bulge could be observed. Incision and drainage of the abscess on a combined cervical-oropharyngeal approach was performed under general anesthesia, associated to non-specific antibiotherapy by parenteral route. Bacteriology was negative. After one week of antibiotherapy, fever persisted with onset of torticollis. A diagnosis of tuberculosis was considered. Tuberculin skin test was positive at 16.5 mm. A second sample by pharyngeal aspiration showed caseous pus with acid-fast bacilli. Cervical spine CT found a retrostyloid abscess with atlantoaxial lysis. Cervical Pott’s disease complicated by Grisel syndrome was diagnosed. Antituberculosis therapy was initiated. Results at five months’ follow-up were satisfactory. Discussion/Conclusion: Parapharyngeal abscess with an etiology of Pott’s disease is rare. Modern imaging is highly contributive to diagnosis and follow-up of lesion regression under treatment. © 2011 Elsevier Masson SAS. All rights reserved.

Introduction Cervical Pott’s disease is rare, at 3 to 20% of tuberculous osteoarticular pathologies [1—5]; locations are much more frequently thoracic, involving the final thoracic vertebrae,

∗ Corresponding author. Tel.: +(00221) 77 6319095 or +(00221) 33 8203364. E-mail address: [email protected] (E.S. Diom).

or lumbar. It is usually revealed by a retropharyngeal abscess [6,7]. We here report the first case of atlantoaxial Pott’s disease revealed by a retrostyloid abscess in the literature.

Observation A seven-year-old boy was admitted to emergency with a three-week history of fluctuating painful left lateral cervical swelling and odynophagia, associated with night sweats.

1879-7296/$ – see front matter © 2011 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.anorl.2010.12.005

152

E.S. Diom et al.

Figure 2 Lateral C-spine x-ray, showing a pinching of corporovertebral interlines and dense prevertebral soft tissue.

Figure 1 Neck stiffness observed on seventh day after admission, before initiation of antitubercular treatment.

General examination found a temperature of 38 ◦ C and a heart rate of 90 bpm. ENT examination found a mild 2 cm trismus, through which a lateral pharyngeal bulge covered by non-ulcerated inflammatory mucosa could be observed. The posterior pillar of the left tonsillar region was swollen, pushing the tonsil forward in a manner suggestive of a retrostyloid abscess. Incision and drainage on a combined cervical-oropharyngeal approach under general anesthesia collected 35 cm3 of pus. Direct bacteriology and culture were negative. Associated i.v. amoxicillin — clavulanic acid (100 mg/kg per day in three doses) and gentamycin (5 mg/kg per day in a single dose) was initiated. On his seventh day in hospital, the patient developed torticollis (Fig. 1) and pulmonary auscultation detected rattling on the right base. Frontal pulmonary lung x-ray found a diffuse bilateral bronchial syndrome associated with a right basal interstitial site. HIV serology was negative. CRP was 24 mg/L (normal, < 6 mg/L). Tuberculin skin test was positive at 16.5 mm. Control blood count found hyperleukocytosis (18,000 white cells/mm3 ). A persistent Grisel syndrome developed, with thickening of the cervical region, and recurrence of cervical and oropharyngeal swelling. Standard cervical spinal x-ray showed pinching of the corporo-vertebral interlines, destruction of the C2 vertebra and dense prevertebral soft tissue (Fig. 2). Cervical CT found lysis of the summit of the odontoid apophysis, with atlantoaxial diastasis, lysis of the anterior C1 arc, and multiloculated parapharyngeal collections (Fig. 3). Repeat posterior pillar drainage by trochar under general anesthesia

collected thick caseous pus. Direct bacteriology found acidfast bacilli (AFB) on Ziehl staining. Culture on Lowenstein medium identified the AFB. Antitubercular polychemotherapy was initiated, first associating isoniazid (H) 5 mg/kg per day, rifampicin (R) 10 mg/kg per day and pyrazinamide (Z) 25 mg/kg per day, with a second phase associating RH for a total course of ten months. A Philadelphia cervical collar was fitted. Evolution at five months was favorable, with weight gain and stable apyrexia. ENT examination found that the fluctuating lateral cervical mass had fistulized. The effusion had ceased, leaving a clean scar. Cervical range of motion,

Figure 3 Cervical CT-scan, showing vertebral lysis and parapharyngeal abscess.

A case of cervical Pott’s disease revealed by parapharyngeal abscess Table 1 Reports of retropharyngeal abscess revealing Pott’s disease. Authors

Cases of retropharyngeal abscess revealing Pott’s disease

Lifeso, 1987 Al Soub, 1996 Brian, 1999 Kooli, 2001 Attia, 2004 Benhammou, 2007

10 1 1 2 1 2

however, remained limited, despite the Minerva jacket. After five months’ antitubercular treatment, standard lateral spinal x-ray showed limitation of the bone lesions, almost complete regression of the prevertebral opacity, and persistent disc pinching.

Discussion Pott’s disease affects the craniocervical junction (suboccipital Pott’s) in 0.3% to 1% of cases, whatever the vertebral location [4]. An atlantoaxial joint location is exceptional, at 0.3% of cases of spinal tuberculosis [5]. In geographic regions where tuberculosis is endemic (poorer Asian, East European and African countries) [5], however, it is a diagnosis to be considered from the earliest stages. Most authors relate delayed consultation to clinical latency [1,2,5], which varies from two months [3] to one year [5], for a mean 10.8 months according to Lifeso [6], in one of the longest series published (12 patients presenting with atlantoaxial Pott’s disease). A cervical location involves a retropharyngeal abscess in 57% of cases according to Pollard [7] and 83% according to Lifeso [6] (Table 1). Isolated lateral pharyngeal abscess revealing Pott’s disease has not previously been reported. Torticollis is non-specific: it is found in more than 80 causes and does not clearly orient diagnosis [8]. It is, however, strongly suggestive of retrostyloid abscess, where it is present in 75% of cases [8]. The oropharyngeal arching may be very slight [8] or more obvious and obstructive, inducing dysphagia, dysphonia or dyspnea [2,9]. Signs of tubercular involvement, such as asthenia, anorexia, weight loss and night sweats, are rarely encountered [1,2]. Biological examinations such as CRP, ESR, CBC and TB skin-test are not systematically positive [1]. Its rarity and clinical latency make cervical Pott’s disease hard to diagnose. Bacteriology, with direct examination using Ziehl-Neelsen staining and culture in Lowenstein-Jensen medium reveals Koch’s bacillus. Histology of the abscess wall or of a satellite lymphadenopathy finds pathognomonic giant-cell epithelial granuloma with central necrosis. Koch’s bacillus is not always immediately isolated in the sample [2,10], which accounts for the delay in the diagnosis of tuberculosis, suspected only after failure of non-specific antibiotherapy. Imaging is very contributive. Standard cervical spinal x-ray may show prevertebral soft tissue thickening, bone lysis with irregularity of the plateau, cysts or vertebral collapse [1,2,5,9]. CT usually finds lysis

153

of the anterior wall of the vertebral plateaux and, in the paravertebral, retropharyngeal or parapharyngeal regions, hypodense multiloculated collections surrounded by a shell, creating effect of mass on the oropharynx. MRI usually finds effusion with hypointense T1 and hyperintense T2 signal [1]. Treatment means and methods are multidisciplinary, involving antituberculosis polychemotherapy and may call on an anesthesiologist, ENT specialist, orthopedic specialist or neurosurgeon. Indications vary with the situation. Intubation under fibroscopy is useful in case of spinal instability and avoids rupturing the abscess [7]. ENT management consists in draining the abscess when large and symptomatic. A Philadelphia cervical collar or halo traction may be needed to stabilize the spine or treat subluxation. Neurosurgery may be indicated in case of neural compression.

Conclusion The clinical latency of cervical Pott’s disease and its sometimes deceptive manifestation usually preclude early diagnosis. Retrostyloid abscess revealing Pott’s disease is an exceptional situation: retropharyngeal locations are more often reported; but it needs to be considered in endemic regions. Imaging is highly contributive to diagnosis and to follow-up of lesions in regression under treatment.

Conflict of interest statement None.

References [1] Benhammou A, Bencheikh R, Benbouzid MA, et al. Abcès rétropharyngés révélant un mal de Pott cervical. Rev Stomatol Chir Maxillofac 2007;108:543—6. [2] Kooli H, Marreckchi M, Tiss M, et al. Les abcès froids parapharyngés sur spondylodiscite. Presse Med 2001;30:19—21. [3] Attia M, Harnof S, Knoller N, et al. Cervical Pott’s disease presenting as a retropharyngeal abscess. Isr Med Assoc J 2004;6:438—9. [4] Wurtz R, Quader Z, Simon D, et al. Cervical tuberculous vertebral osteomyelitis: case report and discussion of the literature. Clin Infect Dis 1993;16:806—8. [5] Al Soub H. Retropharyngeal abscess associated with tuberculosis of the cervical spine. Tubercle and Lung Disease 1996;77(6): 563—5. [6] Lifeso R. Atlanto-axial tuberculosis in adults. J Bone Joint Surg 1987;69-B:183—7. [7] Pollard BA, El-Beheiry H. Pott’s disease with unstable cervical spine, retropharyngeal cold abscess and progressive airway obstruction. Can J Anesth 1999;46:772—5. [8] Lescanne E, Bouetel V, Bakhos D, et al. Torticolis fébrile : le point de vue de l’ORL. Réalités Pédiatriques 2008;128: 1—5. [9] Carroll N, Bain RJI, Tseung MH, Edwards RHT. Tuberculous retropharyngeal abscess producing respiratory obstruction. Thorax 1989;44:599—600. [10] Fraile Rodrigo JJ, Hernandez Martin A, Ortiz Garcia AM, et al. Absceso frio tuberculoso parafaringeo. Presentacion de caso clínico. Acta Otorrinolaring Esp 1988;39:193—5.

Lihat lebih banyak...

Comentários

Copyright © 2017 DADOSPDF Inc.