Hot Seat Denouement: Fever, Neck Tilt

The Case

by Sonny Tat

8 mo previously healthy girl with fever x 7 days. Pt has had fever with Tmax to 103.7. Had episode of eyes rolling back, limp at start of fever, self-resolved. Mom notes slight head tilt to left for 2 days. +URI symptoms, tolerating PO, normal UOP, no vomiting. Fully vaccinated. Has been seen in ED two previous times during this week, most recently yesterday. At that time, she had a UA with negative nitrites/LE, 4 WBC. Patient returns today for persistent fever.

Exam: T 39.9 HR 197 RR 50 100% RA; Better with motrin/PO fluids: T 36.1 HR 150 RR 26

Well-appearing, smiling, interactive

Pt with slight leftward neck-tilt, full-range of passive motion of neck, no swelling or tenderness, MMM, throat non-erythematous, no exudate

Chest CTAB, no wheezing, stridor, or crackles

Heart RR, no murmurs, CRT less than 2 sec

Abd non-tender, no masses, no guarding

You obtain a CBC and blood culture for persistent fever.

WBC 24 K, neutrophils 15 K, bands 1. You review a chest x-ray from yesterday, which is normal. 

You also get a lateral neck: 

The overnight wet read is "diffuse prevertebral soft tissue swelling." It is now 2 am. The patient is awake, very well-appearing, and well-hydrated with reliable parents.

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Teaching Attending Response
by Mike Quinn

I think the baby probably has a retropharyngeal infection. One week of fever, “no source,” CXR and Urine negative at a previous visit, now with a new symptom of “neck tilt,” WBC 24K, and a plain image showing “swelling” of the retropharyngeal space. I could talk myself into this being a RPA.  So antibiotics should be given , and some defining image needs to be done, in order to mobilize the consultants and inpatients, as needed.  Around here,  it falls to the ED to figure out the logistics.  Dave and Dewesh comment on how complex that can be, especially at 2 AM.  Just to make the point: I think in a child who I suspect has RPA I would op for a CT, maybe even in the daytime.  I get the sense that if I got an ultrasound sudy or fluoroscopy, those would ave to be incontrovertibly negative to be of any use.  That is, any abnormality at all and Radiology, ENT, and probably hospitalists will insist on the CT anyway, so I can’t think of instances where those studies have helped me, only times where they’ve delayed the inevitable.

So, get a sedated CT at 2 AM?  Hold that thought.

Because in this patient something bugs me.  Dewesh strongly comments, too.  I imagine going into the room to convey the plan to the parents of the kid with the RPA – the febrile, miserable kid whose neck muscles are in spasm from the inflammation, who can’t swallow because there’s an abscess in the back of his (her?) throat, and hasn’t drunk anything in 2 days. Only: this baby is happy, smiling, wet and hydrated.  He holds his head tilted, but has completely supple neck muscles, and when I stop manipulating the neck, I presume, he goes back to holding his head tilted.  Last time I saw a content child with a head tilt, it was a brain tumor.  Oh, and didn’t he have some kind of eye rolling, limp episode last week that seems to have been chalked up to a benign febrile seizure? I worry that there’s something in the head.

Anyway, I want a non-contrast head CT promptly.  He can get clinda and cef, I can alert ENT about what’s going on, and how I may not get the optimal study right away, but I’ll try, and the child is stable for now, and I know what to monitor meanwhile regarding RPA.  I would try to sweet talk radiology into doing the head CT, and (if negative) keep the baby on the table, maybe with Sweetease and 0.05 mg/kg morphine (for the pain).  I would not perseverate at multiple attempts at the neck CT – one shot is all.  It’s 2 AM, ECIC is calling, to much else going on.  At 7, the day crew can better arrange the neck CT.

Of course, if the head CT is positive, then PICU, Neurosurg and ENT have a lot to deal with, eh?


Your Polled Responses
What antibiotics (if any) would you select for this patient?

 

What is your disposition plan?

 Would you get a neck CT as your next step? This would require sedation.

And the denouement
by Sonny Tat
We admitted the patient to General Medicine that evening and started her on empiric antibiotic coverage with Unasyn. She remained clinically stable with persistent head tilt and no respiratory symptoms. ENT recommended a CT neck with contrast on HD #1. This CT revealed a rim-enhancing 1.4 x 1.7 x 2.2 cm fluid collection on the right consistent with a small retropharyngeal abscess.



On HD#2, she remained febrile on empiric antibiotics. She underwent a successful I&D procedure. Fluid culture showed rare Group A Strep. She was transitioned to Augmentin to finish a 10 day course at home. She returned for scheduled follow-up and was completely recovered.