A Challenging case of Neck Abscess !!!

A Challenging case of Neck Abscess !!!
Dr.Sree Lekshmy.S, Dr.Sajitha Nair, Dr.Sindhu, Dr.Sreya Nair DrC Jayakumar 
Four and half old female presented with high grade intermittent fever with chills, sore throat of 1 day duration . She is noted to have left sided neck swelling. 
She was febrile and irritable with other vitals stable but with bilateral cervical lymphadenopathy largest measuring 1.5 x 1cm in the left side with local warmth and tenderness. Mild torticollis to left side present. 
Labs: TC-18.34ku/ml, N84% L9%,Hb-10.8%, Crp -103.65
Peripheral smear showed normocytic normochromic anaemia with neutrophilic leucocytosis. 
She was started on inj. Augmentin and other symptomatic measures. 
USG Neck showed multiple enlarged discrete hypoechoic lymphnodes in left Ib, II, III and V, largest and most numerous in left level V, largest measuring 19x8mm, most of them show early suppurative changes within. 
No conglomeration/ matting/ abscess formation. 
Thickening of surrounding soft tissue. 
On the right, prominent level Ib, V nodes with preserved fatty hilum. 
No suppurative changes. 
Thyroid and submandibular glands appears normal. 
Impression: Left sided cervical lymphadenitis with early suppuration and abscess. 
Child had persistent fever spikes, increasing torticollis, increasing CRP(103-150) , hence a clinical possibility of retropharyngeal abscess was considered. 
Xray Soft tissue neck lateral view (two  days after admission)showed widening of pre vertebral space and adenoid hypertrophy. MDCT Neck with contrast showed Prominent prevertebral soft tissue with linear hypodensity at C2-C6 level extending from the retropharyngeal space. 
May represent evolving prevertebral abscess, 
As cervical lymphadenopathy was persisting Antibiotics were upgraded to Inj Ceftriaxone and Clindamycin. 
At this point Retro pharyngeal abcess I & D done under GA
No pus collection was noted, unhealthy friable submucosa noted at C4 – C5 level, same removed and sent for Bacterial smear and C&S, AFB smear and AFB culture, gene expert and HPE. 
All were negative except for Pus c/s -showing scanty growth of Streptococcus species, Sensitive to Ceftriaxone, Clindamycin Vancomycin,Cefotaxime, Ofloxacin, Chloramphenicol, Linezolid, Levofloxacin and resistant to pencillins. Repeat CRP, even after surgical intervention was increasing from 150.10 to 199.78 inspite of decrease in total count from 28.72 to 16.49. 
The child persisted to have high grade intermittent fever ranging from 102 to 104 *F despite of sensitive antibiotics. The child remained extremely irritable and developed non purulent conjunctivitis and severe oro-mucosal changes.
Differentials considered: Incomplete Kawasaki disease, scarlet fever, Viral infections like EBV, CMV, adenovirus, JIA, SJS.
In view of rising CRP and labs showing normocytic normochromic anemia and falling s.albumin, a clinical possibility of incomplete Kawasaki Disease was considered and ECHO was done, which showed structurally normal heart ,normal biventricular function and diffuse prominance of coronaries. 
The size and the z scores for the coronaries were normal. No obvious dilatation/ectasia/aneurysm of coronaries. 
Later child also developed a strawberry tongue with severe oro mucosal changes. Child was administered IVIg @ 2g/kg and aspirin. 
She improved clinically within 24 hrs and became symptomatically better and afebrile. ECHO repeated prior to discharge was within normal limits. Inj Ceftriaxone was given for 12 days and Clindamycin was given for a total of 10 days. 
DISCUSSION:
Deep neck infections (DNIs) is a rare manifestation of KD, which include retropharyngeal, parapharyngeal, and peritonsillar abscess. 
Many of the KD patients with retropharyngeal space inflammation have not found abscesses or liquefaction fine-needle aspiration. However, the causal relationship between the retropharyngeal space inflammation and KD is still difficult to distinguish. Some researchers consider that the retropharyngeal abnormalities in KD are presumably linked to the vasculitis of microvessels that cause edema and inflammation, which is a non-infectious inflammatory reaction. But some researchers consider that the infection of some bacteria such as staphylococcal and streptococcal toxin as superantigens may be involvement in the pathogenesis of KD. In this condition, early suspicion of KD and subsequent satisfactory response to IVIG may avoid the need for antibiotic treatment or invasive procedures such fine needle aspiration or surgical explorations. However, if neck CT showed a retropharyngeal space abscess, surgical intervention often indicates that there may be a purulent bacterial infection and may be involved in the onset of KD.DNIs that show a poor response to initial intravenous antibiotics,  could be early presentations of KD.
Kawasaki Disease (KD):
Introduction: It is characterised vasculitis of the medium-sized arteries and second most common vasculitis in childhood Approximately 75% of cases occur under 5 years of age. Less common in children <6 months and >5 years; however these children are more likely to develop Coronary artery aneurysm(CAA). 
Diagnostic criteria : Fever persisting for 5 days, + 4 of the 5 following criteria
Conjunctival congestion- bilateral non exudative
Rash – anything except bullous,vesicular or petechial rashes
Strawberry tongue
Unilateral tender cervical lymphadenopathy
Hyperemia nad painful edema of hands and feet, that progress to desquamation
KD can be diagnosed with less than four of the following features if coronary artery abnormalities are present. 
Incomplete Kawasaki Disease :
Consider in a child with a clinical presentation suggestive of KD but not meeting the full diagnostic criteria. Requires investigation results to support the diagnosis. Infants and adolescents often present with an incomplete picture and are at a higher risk for cardiac complications. Consider incomplete KD in: A child with fever for at least 5 days combined with 2 or 3 of the principal clinical features or an infant with one/more of the following features: fever ≥7 days +/- irritability without other explanation, prolonged fever and unexplained aseptic meningitis, A child or infant with prolonged fever and shock, cervical adenitis not responsive to oral antibiotics.
Management: INTRAVENOUS IMMUNOGLOBULIN (IVIg): 2 g/kg as a single IV infuse. Post IVIg treatment- live vaccines (eg measles and varicella) should be deferred. ASPIRIN  3-5 mg/kg orally as a daily dose until normal echo on follow up (minimum 6 weeks). Avoid non-steroid anti-inflammatory medications while on aspirin.