AN ATYPICAL PRESENTATION OF TB: A CASE REPORT

SESSION TITLE: Chest Infections 2 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Mycobacterium tuberculosis is the leading infectious cause of death from any single organism in adults. More than two billion people are estimated to be infected with TB worldwide. It usually involves the lungs, but can also present as extrapulmonary TB. (approximately two thirds of people will have pulmonary tuberculosis while less than a third of immuncompetent individuals will have extrapulmonary tuberculosis alone) The diagnosis of extrapulmonary TB can be difficult and often requires a high index of suspicion. We present a case of TB that manifested as a tubercular retropharyngeal abscess. CASE PRESENTATION: A 67 year old female from Vietnam presented complaining of 2 months of worsening posterior neck pain, which progressed to dysphagia to liquids and solids and was associated with weight loss. At presentation she denied any fevers, chills, chest pain, cough, hemoptysis or any other symptoms. On examination she was afebrile, well appearing with normal vital signs, normal pulmonary, cardiac and abdominal examination; but she had left anterior neck tenderness to palpation. Laboratory data was unrevealing. She underwent MRI of the cervical spine to evaluate her neck pain, and the MRI showed C1-C2 retropharyngeal abscess with osteomyelitis of C2 with considerable bone destruction. A Barium swallow study showed a fistulous connection to the retropharygeal space. A CT scan of the chest showed multiple bilateral pulmonary nodules. She underwent incision and drainage of the retropharyngeal abscess with significant improvement in symptoms . Abscess drainage grew Klebsiella pneumoniae. The smear was negative for AFB, but the culture became positive after 21 days for pan-susceptible Mycobacterium Tuberculosis. Gastric drainage and sputum AFB were negative. She was started on high dose steroids and anti-tuberculous treatment after the culture from the retropharyngeal abscess became positive. A PEG tube was placed for nutrition and administration of medications. After 6 weeks of anti-tuberculous treatment and steroid therapy,a fluoroscopy swallow study was repeated which showed resolution of the previously seen fistula and a significant decrease in the size of the retropharyngeal abscess. She completed one year of anti-tuberculous treatment for osteomyelitis related to Mtb. DISCUSSION: Tubercular retropharyngeal abscess is an uncommon cause of neck pain and dysphagia and is an atypical presentation of tuberculosis. It requires a detailed history and physical exam in addition to a high index of suspicion. Early recognition and treatment is essential to prevent serious complications from mediastinitis, airway obstruction, up to paraplegia that could be caused from severe osteomyelitis. CONCLUSIONS: TB is a disease with high prevalence worldwide. TB can have many different clinical presentations and is important to keep it in consideration as differential diagnosis in suspicious cases. Reference #1: Colmenero JD, Jiménez-Mejías ME, Reguera JM, Palomino-Nicás J, Ruiz-Mesa JD, Márquez-Rivas J, et al. Tuberculous vertebral osteomyelitis in the new millennium: Still a diagnostic and therapeutic challenge. Eur J Clin Microbiol Infect Dis. 2004;23:477–83 Reference #2: Marques PM, Spratley JE, Leal LM, Cardoso E, Santos M. Parapharyngeal abscess in children: Five year retrospective study. Braz J Otorhinolaryngol. 2009;75:826–30 Reference #3: Harkani A, Hassani R, Ziad T, Aderdour L, Nouri H, Rochdi Y, et al. Retropharyngeal abscess in adults: Five cases reports and review of the literature. Scientific World Journal. 2011;11:1623–9. DISCLOSURES: no disclosure on file for Ashkin David; No relevant relationships by Megan Ninneman, source=Web Response No relevant relationships by Yoslay Perez, source=Web Response No relevant relationships by Rene Rico, source=Web Response No relevant relationships by Andreas Schmid, source=Web Response