CASE REPORT


https://doi.org/10.5005/jp-journals-11010-1075
Indian Journal of Respiratory Care
Volume 12 | Issue 4 | Year 2023

An Unusual Case of Retropharyngeal Tubercular Abscess Due to Cervical Pott’s Spine with Mediastinal Tubercular Lymphadenopathy: A Case Report


Islahuzzama S Ansari1, Sachinkumar S Dole2https://orcid.org/https://orcid.org/0000-0002-1805-1725

1,2Department of Respiratory Medicine, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth University, Pune, Maharashtra, India

Corresponding Author: Sachinkumar S Dole, Department of Respiratory Medicine, Dr. D.Y. Patil Medical College, Hospital & Research Centre, Dr. D.Y. Patil Vidyapeeth University, Pune, Maharashtra, India, Phone: +91 9637104972, e-mail: sachindole85@gmail.com

Received: 12 July 2023; Accepted: 18 November 2023; Published on: 18 January 2024

ABSTRACT

Introduction: Tuberculosis (TB) including extrapulmonary tuberculosis is one of the most common diseases in developing countries like India. Spinal tuberculosis (Pott’s spine) usually involves thoracolumber spine and rarely affects cervical spine. In addition retropharyngeal abscesses of tubercular origin are also one of rare presentations of cervical spine tuberculosis.

Case description: We present a rare case of a 27-year-old female with a history of tubercular retropharyngeal abscess (RPA) associated with spinal tuberculosis (TB) (Pott’s spine) involving the cervical spine. The patient was successfully managed with drainage of the abscess and antitubercular treatment (ATT). She later on had a recurrence of extrapulmonary TB in the form of mediastinal lymph node mass (drug-sensitive TB), which is rare in adults and was treated successfully with ATT. Such recurrence of extrapulmonary TB (drug-sensitive) in previously successfully treated cases of retropharyngeal tubercular abscess is an uncommon presentation of TB.

Conclusion: Retropharyngeal abscess is one of the rare presentations of cervical Pott’s spine. Despite its rarity, it should be aggressively treated due to life threatening complications. In case of its recurrence; other extrapulmonary lesions like mediastinal lymphadenopathy should be considered in diagnostic workup.

How to cite this article: Ansari IS, Dole SS. An Unusual Case of Retropharyngeal Tubercular Abscess Due to Cervical Pott’s Spine with Mediastinal Tubercular Lymphadenopathy: A Case Report. Indian J Respir Care 2023;12(4):358–361.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.

Keywords: Case report, Lymphadenopathy, Pott’s spine, Recurrence, Retropharyngeal abscess, Tuberculosis

INTRODUCTION

Tuberculosis (TB) is one of the most common diseases in developing countries like India. Extrapulmonary TB most commonly affects lymph nodes followed by pleura, gastrointestinal organs, bones and joints, and the central nervous system.1 Pott’s spine is one of the presentations of TB, which usually involves the thoracic and lumbar spine. TB affecting the cervical spine is unusual and seen in approximately 0.03% of cases.2 Retropharyngeal abscesses (RPA) are usually of bacterial origin; they may exist alone or with cervical osteomyelitis.3,4 RPA due to TB is also a rare presentation. We report an unusual case of retropharyngeal tubercular abscess due to cervical Pott’s spine with mediastinal lymphadenopathy treated with antitubercular treatment (ATT).

CASE DESCRIPTION

A 27-year-old female went to a general practitioner with complaints of fever and dysphagia to both solids and liquids for 1 month. She had no past history of TB. On throat examination, swelling on the posterior pharyngeal wall was visible (Fig. 1). She was given oral medications by the general practitioner and referred to an outside hospital for further management. She was subjected to routine blood biochemical and hematological investigations, which were found to be normal. Simultaneously, she underwent chest radiography and magnetic resonance imaging (MRI) of the neck. Her chest radiography didn’t reveal any abnormality, while an MRI of the neck revealed a well-defined hyperintense collection in the left pharyngeal mucosal space extending to the left perivertebral space with erosion C7 and D1 vertebral bodies suggestive of RPA with Pott’s spine (Fig. 2). She was later on referred to a surgeon for drainage of abscess. After drainage of the abscess, pus was sent for culture and sensitivity and a cartridge-based nucleic acid amplification test (CB-NAAT) for acid-fast bacillus (AFB). She was started on antitubercular therapy for 6 months based on pus for CBNAAT report, which revealed the presence of Tubercle bacilli, sensitive to rifampicin.

Fig. 1: Posterior pharyngeal wall swelling

Fig. 2: Magnetic resonance imaging (MRI) neck showing well-defined hyperintense collection in left pharyngeal mucosal space and extending to the left perivertebral space with erosion of C7 and D1 vertebral bodies

After 5 months of completing treatment, she again developed fever and breathlessness. This time, the patient came to our hospital for further management. Her chest radiography revealed paratracheal opacities (Fig. 3). On MRI neck, there was a resolution of earlier lesions (Fig. 4). She was subjected to computed tomography (CT) thorax for further evaluation, which revealed mediastinal mass (conglomerated lymph nodes) in subcarinal and paratracheal area compressing airways (Fig. 5). Provisional diagnosis of lymphoma, recurrence of TB was considered. Later on, she underwent a guided biopsy of the lymph node mass, and the biopsy tissue samples were sent for investigations, which included histopathology, culture and sensitivity and CBNAAT for AFB. Once again, her CBNAAT revealed the presence of tubercle bacilli, which are sensitive to rifampicin. Her histopathology report had features of chronic necrotizing granulomatous lesion suggestive of tubercular etiology. She was restarted on drug-sensitive TB regimen [two (isoniazid + rifampicin + pyrazinamide + ethambutol) + four (isoniazid + rifampicin + ethambutol)] for 6 months. The patient came for a follow-up after completion of ATT, and she was subjected to CT thorax. There was complete resolution of symptoms, and her follow-up CT thorax revealed complete resolution of lymph node mass (Fig. 6). She remained asymptomatic during her routine follow-up.

Fig. 3: Chest X-ray suggestive of paratracheal opacities (white arrow)

Fig. 4: Repeat MRI thorax and whole spine screening resolution of abscess and no new lesions seen

Fig. 5: Computed tomography (CT) of the thorax suggestive of centrally necrotic peripherally enhancing lymph nodes in the subcarinal region

Fig. 6: Computed tomography (CT) of the thorax suggestive of complete resolution of lymph node mass

DISCUSSION

Extrapulmonary TB represents approximately 15% of all TB infections.5 It affects the lymph nodes most frequently, followed by pleural infection.5 The retropharyngeal space is a deep neck space surrounded by buccopharyngeal fascia anteriorly and alar fascia posteriorly; it extends between the base of the skull superiorly and the mediastinum inferiorly.6 Retropharyngeal abscesses (RPA) are common in children <5 years of age. Abscesses in this group are classically secondary to upper respiratory infections, especially oropharyngeal infections, while in the adults are usually caused by direct invasion of pyogenic pathogens into retropharyngeal space by trauma to the pharynx or esophagus (usually from a foreign body, traumatic endoscopy or esophageal intubation).

Retropharyngeal abscess (RPA) is most commonly caused by bacterial infections, as reported in several case reports.3,4 In a systemic review of 210 cases done by Parhiscar and Har-El,3 the most common pathogen involved was streptococcus viridians (39%), followed by staphylococcus epidermidis (22%) and staphylococcus aureus (22%) while clinical review done by Goldenberg et al.4 the most common pathogen isolated was Streptococcus pyogenes. RPA is a rare presentation of TB, and it occurs either due to tubercular involvement of the lymph nodes in the retropharyngeal space7 or, more commonly, due to tubercular involvement of the cervical spine.8

Mediastinal lymph node enlargement is an uncommon feature of intrathoracic TB in adults, whereas it is the rule of primary TB in children.9 Our patient, a 27-year-old female, when she came to us, had already received treatment for RPA with Pott’s spine in the form of drainage of the abscess and ATT for 6 months. She was symptomatic when presented to us, and further workup revealed an intrathoracic lesion in the form of conglomerate enlarged lymph nodes. Based on clinical and radiological features, diagnoses of lymphoma and drug-resistant tubercular lymphadenopathy were considered. Subsequent diagnostic workup of biopsy of the lymph node mass (histopathology) revealed to be of tubercular etiology. To our surprise, on CBNAAT testing, it was found to be of drug-sensitive TB. The patient was restarted on ATT for 6 months, and there was complete clinical and radiological resolution.

As per the literature, recurrence of pulmonary TB is common, but recurrence of extrapulmonary TB is rare in spite of taking the full course of ATT. In our case, in spite of the successful treatment of RPA, she subsequently developed mediastinal lymphadenopathy, which was found to be of tubercular etiology.

Early recognition of mediastinal lymphadenopathy is important since prompt treatment may result in shrinkage and disappearance of the nodes if they have not undergone extensive caseation. Hence, it is advised to always screen the patient for other extrapulmonary lesions if there is a recurrence of symptoms.

CONCLUSION

Through this case report, we would like to emphasize to treating physicians that RPA may be the presenting sign of cervical Pott’s spine. Despite its rarity, this entity should be considered to ensure appropriate diagnosis and treatment. In case of recurrence of symptoms, an aggressive workup for other extrapulmonary lesions like mediastinal lymphadenopathy should be considered.

Clinical Significance

Our patient had Pott’s spine involving cervical vertebrae with RPA of tubercular origin at the time of initial presentation. Both cervical Pott’s spine and RPA are rare forms of extrapulmonary TB. In spite of successfully managing both these conditions, she again developed extrapulmonary TB in the form of mediastinal lymph node mass, which was found to be drug-sensitive. Such recurrence of drug-sensitive extrapulmonary TB is an extremely rare presentation.

TAKE HOME MESSAGES

ORCID

Sachinkumar S Dole https://orcid.org/https://orcid.org/0000-0002-1805-1725

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