JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
494
NOVEMBER, 1976
Tuberculosis of the Cervical Spine Presenting as Retropharyngeal Abscess JOSEPH M. STINSON, M.D., Associate Professor of Medicine and Physiology, Macy Faculty, Fellow, Meharry Medical College, Nashville, Tennessee
the progressive decline in the incidence of tuberculosis in this country, unusual presentations of the disease are less likely to be promptly considered and diagnosed. This is especially true for extrapulmonary tuberculosis. The reduction in pulmonary tuberculosis has been paralleled by decrease in the incidence of skeletal tuberculosis, with the latter accounting for approximately one per cent of patients hospitalized for tuberculosis."2 Tuberculosis of the vertebral spine occurs in only one-half of the patients with skeletal tuberculosis, with the disease most often involving the lower thoracic and the lumbar spine."4 Thus, tuberculosis of the cervical spine is uncommon. Its presentation as retropharyngeal abscess is rare, with only 11 known cases previously reported.5 This, together with the decline in tuberculosis in general, makes it unlikely that one would immediately consider tuberculosis as the cause of retropharyngeal abscess. The following case report should serve as a reminder that tuberculosis, in all of its various manifestations, is still very much among us. ITH
CASE REPORT
A 63-year-old man was admitted to the Nashville VA Hospital in May, 1974 with a sevenmonth history of pain and stiffness in his neck and shoulders. For two months he had noted mild hoarseness and dysphagia with occasional regurgitation of liquids. He denied cough or sputum production, weakness, weight loss, chills, fever or night sweats. He had never knowingly had tuberculosis or tuberculous contacts. Past medical history was significant in that he was known to have had pericardial calcification since 1963 with frequent episodes of atrial fibrillation
and atrial flutter, occasionally requiring cardioversion. He also had known positive skin tests for tuberculosis and histoplasmosis. Examination of the throat revealed a large, firm submucosal cystic mass in the right posterolateral oropharyngeal wall. No lymph nodes were palpable and breath sounds were clear. The cardiac examination showed an irregular irregularity with a grade 3/6 pansystolic murmur at the apex and along the left sternal border. A pericaridal knock was also present along the left sternal border. No gallops, bruits, or jugular venous distention were present. There was a trace of pitting pedal edema. The white blood cell count was
Fig. 1. Chest roentgenogram. A. Posteroanterior, showing left lower lung field fibrosis. B. Lateral, more clearly demonstrating calcification of inferior pericairdium. No acute infiltrates.
6,600 per cubic millimeter, hematocrit 38%, and sedimentation rate 46 mm per minute. Chest roentgenogram demonstrated pericardial calcification along the diaphragmatic portion of the heart with fibrotic changes in the left lower lung (Fig. 1). No acute infiltrates were present. Cervical spine films showed cortical destruction of the third and fourth cervical vertebrae with loss of disc space (Fig. 2A). The retropharyngeal mass was aspirated, disclosing grossly purulent material positive for acid fast bacilli on smear. A few days later he had partial excision of the cyst wall, microscopic examination of which demonstrated granulomatous reaction and acid fast organisms. He was treated
Vol. 68, No. 6
TB of the Cervical Spine
for one month with isoniazid, rifampin and streptomycin, and thereafter with isoniazid alone. After being fitted with a SOMI brace, he was discharged from the hospital in July, 1974. By October, 1974, the involved cervical vertebrae had fused spontaneously (Fib. 2B), he remained asymptomatic and the brace was discontinued. He continued taking daily isoniazid until June, 1976. DISCUSSION
Retropharyngeal infection is considered largely a disease of children, related to retropharyngeal lymph nodes usually absent in the adult.6 This, together with the rarity of cervical spinous tuberculosis, makes it unlikely that one would consider tuberculosis immediately in the differential diagnosis of an adult patient presenting with a retro-
495
spread to the bones.34 Therapy for Pott's disease has evolved from spinal fusion to chemotherapy, aspiration of any abscesses formed and immobilization and other supportive measures.9'10 Results are as good as with surgery, as shown in the present case, probably reflecting the lower colony count of organisms in spinal lesions than in pulmonary disease." Although two or three antituberculous drugs are recommended for spinal tuberculosis," the patient was treated with triple therapy for only one month and with isoniazid alone thereafter, suggesting that long term therapy with more than one drug may not be necessary. SUMMARY
A Fig. 2. Cervical spine roentgenograms. A. Admission, demonstrating cortical destruction of C-3 and 4 with loss of disc space and bulging retropharyngeal soft tissue mass. B. After drainage of abscess, immobilization and five months of chemotherapy. C-3 and 4 are now fused spontaneously.
pharyngeal abscess. Osseous tuberculosis usually results from hematogenous spread from the lungs.2 The patient reported here had no pulmonary lesions or known prior history of tuberculous exposure. He did have positive TB skin tests and pericardial calcification, the latter representing a healed stage of tuberculous pericarditis.7 As much as 20% of all types of pericarditis is tuberculous in origin, either proven or suspected.8 Thus it seems likely that the patient presented here previously had undiagnosed tuberculosis pericarditis. Infection of the cervical vertebrae undoubtedly represented reactivation of this or some other quiescent focus of tuberculosis with hematogenous
A patient with tuberculosis of the cervical spine, presenting as a retropharyngeal abscess and pericardial calcification, is discussed. It is surmised that the cervical tuberculosis represented reactivation of previously undiagnosed tuberculous pericarditis. Treatment with triple therapy for one month and a single antituberculous drug for two years thereafter effected a cure. This case should remind us that, although the incidence of tuberculosis has declined dramatically over the past two decades, it still occurs in all of its forms. LITERATURE CITED
1. DAVIDSON, P. T. and I. HOROWITZ. Skeletal Tuberculosis. Am. J. Med., 48:77-84, 1970. 2. WALDVOGEL, F. A. and G. MEDOFF, and M. N. SWARTZ. Osteomyelitis: A Review of Clinical Features, Therapeutic Consideration and Unusual Aspects. New Engl. J. Med., 282:316-322, 1970. 3. MARCQ, M. and 0. P. SHARMA. Tuberculosis of the Spine: A Reminder. Chest, 63:403408, 1973. 4. MILES, W. A. Osseous Tuberculosis. J. Nat. Med. Assoc., 66:400-403, 1974. 5. NEUMANN, J. L. and D. P. SCHLEUTER. Retropharyngeal Abscess as the Presenting Feature of Tuberculosis of the Cervical Spine. Am. Rev. Resp. Dis., 110:508-511, 1974.
(Concluded on page 542)
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
542
LOOKING UPWARD
J~~~~~~~~~~~~.l~ ~ ~ ~~~~~I ~
i~~~~~
d
William Clark, (1.) smiles at Ensign Ernest Harton. Kevin Clark (r.), Chief Frank Fountaine's chevrons
(behind).
was waiting to receive us in the tradition hallowed Bancroft Hall. The Commandant met us in the magnificent splendor of the Grand Hall and carried us to one of the roped off areas with special furniture, where he gave a remarks of welcome and answered questions freely. The group next had lunch downstairs in the massive Midshipmen's Dining Room and were taken out to watch the formation of the Plebes before they marched in, about 1400 of them, to the Dining Room for their meal. This was to the music of the Academy Band. Our group then strolled by several of the Halls between which there were playing fields on which
nefield,
NOVEMBER, 1976
soccer games were in progress. The youngsters were told that they could engage in any sport, as the Academy had facilities for all. After the relaxation of a short romp on one of the fields, Lt. Richie showed a full length film on what Plebe year was like at Annapolis. We were then given a tour of the museum of the Academy where there were models of famous ships since the time of John Paul Jones and many other Naval memorabilia. Each of the young people was given a packet of materials on the Academy and we were driven home with the same escort officers who were now pals of the youngsters. Through the courtesy of Captain James Hogg, executive assistant to Adm. Watkins, each boy and girl was given a print of the photograph shown in this article of our group on the steps of the Academy. Subsequent comments from the children and their parents have indicated that the eyes of the children had been opened to career possibilities of which they had not been aware. Although this activity was directed toward the Navy specifically, it stimulated an awareness that there are many other possibilities open to young people today who would aspire to them. No one could, of course, predict how many of the young will be absorbed into opportunities in the Navy, but this pilot experience seems to have shown that approaching young people at the earliest possible age will yield greater positive results. After all, people, young or adult, cannot aspire to careers of which they know nothing. Thus we say, "Go Navy." W. MONTAGUE COBB, M.D.
LITERATURE CITED 1. COBB, W. M. The Strait Gate: A Story of a Principle and the Adherence Thereto. JNMA, v. 47, pp. 343-353, 1955. A Cruise on the Aircraft Carrier Ranger, 2. CVA-61, 1968. JNMA, v .66, pp. 344-349, 352,
1974.
(Stinson, from page 495)
6. BRYAN, C. S. and B. G. KING and R. E. BRYANT. Retropharyngeal Infection in Adults. Arch. Intern. Med., 134:127-130, 1974. 7. SCHEPERS, G. W. H. Tuberculous Pericarditis. Am. J. Cardiol., 9:248-276, 1962. 8. HAGEMAN, J. H. and N. D. D'Esopo and W. W. GLENN. Tuberculosis of the Pericardium. New Engl. J. Med., 270:327-332, 1964. 9. American Thoracic Society. The Present Status of Skeletal Tuberculosis. Am. Rev Resp. Dis., 88:272-274, 1963.
10. CHOFNAS, I. and N. E. SURRETT and H. D. SEVERN. Pott's Disease treated without Spinal Fusion. Am. Rev. Resp. Dis., 90:888-898, 1964. 11. Medical Research Council. A Controlled Trial of Ambulant Out-patient Treatment and In-patient Rest in Bed in the Management of Tuberculosis of the Spine in Young Korean Patients on Standard Chemotherapy. J. Bone and Joint Surg., 55:678-697, 1973.
494
NOVEMBER, 1976
Tuberculosis of the Cervical Spine Presenting as Retropharyngeal Abscess JOSEPH M. STINSON, M.D., Associate Professor of Medicine and Physiology, Macy Faculty, Fellow, Meharry Medical College, Nashville, Tennessee
the progressive decline in the incidence of tuberculosis in this country, unusual presentations of the disease are less likely to be promptly considered and diagnosed. This is especially true for extrapulmonary tuberculosis. The reduction in pulmonary tuberculosis has been paralleled by decrease in the incidence of skeletal tuberculosis, with the latter accounting for approximately one per cent of patients hospitalized for tuberculosis."2 Tuberculosis of the vertebral spine occurs in only one-half of the patients with skeletal tuberculosis, with the disease most often involving the lower thoracic and the lumbar spine."4 Thus, tuberculosis of the cervical spine is uncommon. Its presentation as retropharyngeal abscess is rare, with only 11 known cases previously reported.5 This, together with the decline in tuberculosis in general, makes it unlikely that one would immediately consider tuberculosis as the cause of retropharyngeal abscess. The following case report should serve as a reminder that tuberculosis, in all of its various manifestations, is still very much among us. ITH
CASE REPORT
A 63-year-old man was admitted to the Nashville VA Hospital in May, 1974 with a sevenmonth history of pain and stiffness in his neck and shoulders. For two months he had noted mild hoarseness and dysphagia with occasional regurgitation of liquids. He denied cough or sputum production, weakness, weight loss, chills, fever or night sweats. He had never knowingly had tuberculosis or tuberculous contacts. Past medical history was significant in that he was known to have had pericardial calcification since 1963 with frequent episodes of atrial fibrillation
and atrial flutter, occasionally requiring cardioversion. He also had known positive skin tests for tuberculosis and histoplasmosis. Examination of the throat revealed a large, firm submucosal cystic mass in the right posterolateral oropharyngeal wall. No lymph nodes were palpable and breath sounds were clear. The cardiac examination showed an irregular irregularity with a grade 3/6 pansystolic murmur at the apex and along the left sternal border. A pericaridal knock was also present along the left sternal border. No gallops, bruits, or jugular venous distention were present. There was a trace of pitting pedal edema. The white blood cell count was
Fig. 1. Chest roentgenogram. A. Posteroanterior, showing left lower lung field fibrosis. B. Lateral, more clearly demonstrating calcification of inferior pericairdium. No acute infiltrates.
6,600 per cubic millimeter, hematocrit 38%, and sedimentation rate 46 mm per minute. Chest roentgenogram demonstrated pericardial calcification along the diaphragmatic portion of the heart with fibrotic changes in the left lower lung (Fig. 1). No acute infiltrates were present. Cervical spine films showed cortical destruction of the third and fourth cervical vertebrae with loss of disc space (Fig. 2A). The retropharyngeal mass was aspirated, disclosing grossly purulent material positive for acid fast bacilli on smear. A few days later he had partial excision of the cyst wall, microscopic examination of which demonstrated granulomatous reaction and acid fast organisms. He was treated
Vol. 68, No. 6
TB of the Cervical Spine
for one month with isoniazid, rifampin and streptomycin, and thereafter with isoniazid alone. After being fitted with a SOMI brace, he was discharged from the hospital in July, 1974. By October, 1974, the involved cervical vertebrae had fused spontaneously (Fib. 2B), he remained asymptomatic and the brace was discontinued. He continued taking daily isoniazid until June, 1976. DISCUSSION
Retropharyngeal infection is considered largely a disease of children, related to retropharyngeal lymph nodes usually absent in the adult.6 This, together with the rarity of cervical spinous tuberculosis, makes it unlikely that one would consider tuberculosis immediately in the differential diagnosis of an adult patient presenting with a retro-
495
spread to the bones.34 Therapy for Pott's disease has evolved from spinal fusion to chemotherapy, aspiration of any abscesses formed and immobilization and other supportive measures.9'10 Results are as good as with surgery, as shown in the present case, probably reflecting the lower colony count of organisms in spinal lesions than in pulmonary disease." Although two or three antituberculous drugs are recommended for spinal tuberculosis," the patient was treated with triple therapy for only one month and with isoniazid alone thereafter, suggesting that long term therapy with more than one drug may not be necessary. SUMMARY
A Fig. 2. Cervical spine roentgenograms. A. Admission, demonstrating cortical destruction of C-3 and 4 with loss of disc space and bulging retropharyngeal soft tissue mass. B. After drainage of abscess, immobilization and five months of chemotherapy. C-3 and 4 are now fused spontaneously.
pharyngeal abscess. Osseous tuberculosis usually results from hematogenous spread from the lungs.2 The patient reported here had no pulmonary lesions or known prior history of tuberculous exposure. He did have positive TB skin tests and pericardial calcification, the latter representing a healed stage of tuberculous pericarditis.7 As much as 20% of all types of pericarditis is tuberculous in origin, either proven or suspected.8 Thus it seems likely that the patient presented here previously had undiagnosed tuberculosis pericarditis. Infection of the cervical vertebrae undoubtedly represented reactivation of this or some other quiescent focus of tuberculosis with hematogenous
A patient with tuberculosis of the cervical spine, presenting as a retropharyngeal abscess and pericardial calcification, is discussed. It is surmised that the cervical tuberculosis represented reactivation of previously undiagnosed tuberculous pericarditis. Treatment with triple therapy for one month and a single antituberculous drug for two years thereafter effected a cure. This case should remind us that, although the incidence of tuberculosis has declined dramatically over the past two decades, it still occurs in all of its forms. LITERATURE CITED
1. DAVIDSON, P. T. and I. HOROWITZ. Skeletal Tuberculosis. Am. J. Med., 48:77-84, 1970. 2. WALDVOGEL, F. A. and G. MEDOFF, and M. N. SWARTZ. Osteomyelitis: A Review of Clinical Features, Therapeutic Consideration and Unusual Aspects. New Engl. J. Med., 282:316-322, 1970. 3. MARCQ, M. and 0. P. SHARMA. Tuberculosis of the Spine: A Reminder. Chest, 63:403408, 1973. 4. MILES, W. A. Osseous Tuberculosis. J. Nat. Med. Assoc., 66:400-403, 1974. 5. NEUMANN, J. L. and D. P. SCHLEUTER. Retropharyngeal Abscess as the Presenting Feature of Tuberculosis of the Cervical Spine. Am. Rev. Resp. Dis., 110:508-511, 1974.
(Concluded on page 542)
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
542
LOOKING UPWARD
J~~~~~~~~~~~~.l~ ~ ~ ~~~~~I ~
i~~~~~
d
William Clark, (1.) smiles at Ensign Ernest Harton. Kevin Clark (r.), Chief Frank Fountaine's chevrons
(behind).
was waiting to receive us in the tradition hallowed Bancroft Hall. The Commandant met us in the magnificent splendor of the Grand Hall and carried us to one of the roped off areas with special furniture, where he gave a remarks of welcome and answered questions freely. The group next had lunch downstairs in the massive Midshipmen's Dining Room and were taken out to watch the formation of the Plebes before they marched in, about 1400 of them, to the Dining Room for their meal. This was to the music of the Academy Band. Our group then strolled by several of the Halls between which there were playing fields on which
nefield,
NOVEMBER, 1976
soccer games were in progress. The youngsters were told that they could engage in any sport, as the Academy had facilities for all. After the relaxation of a short romp on one of the fields, Lt. Richie showed a full length film on what Plebe year was like at Annapolis. We were then given a tour of the museum of the Academy where there were models of famous ships since the time of John Paul Jones and many other Naval memorabilia. Each of the young people was given a packet of materials on the Academy and we were driven home with the same escort officers who were now pals of the youngsters. Through the courtesy of Captain James Hogg, executive assistant to Adm. Watkins, each boy and girl was given a print of the photograph shown in this article of our group on the steps of the Academy. Subsequent comments from the children and their parents have indicated that the eyes of the children had been opened to career possibilities of which they had not been aware. Although this activity was directed toward the Navy specifically, it stimulated an awareness that there are many other possibilities open to young people today who would aspire to them. No one could, of course, predict how many of the young will be absorbed into opportunities in the Navy, but this pilot experience seems to have shown that approaching young people at the earliest possible age will yield greater positive results. After all, people, young or adult, cannot aspire to careers of which they know nothing. Thus we say, "Go Navy." W. MONTAGUE COBB, M.D.
LITERATURE CITED 1. COBB, W. M. The Strait Gate: A Story of a Principle and the Adherence Thereto. JNMA, v. 47, pp. 343-353, 1955. A Cruise on the Aircraft Carrier Ranger, 2. CVA-61, 1968. JNMA, v .66, pp. 344-349, 352,
1974.
(Stinson, from page 495)
6. BRYAN, C. S. and B. G. KING and R. E. BRYANT. Retropharyngeal Infection in Adults. Arch. Intern. Med., 134:127-130, 1974. 7. SCHEPERS, G. W. H. Tuberculous Pericarditis. Am. J. Cardiol., 9:248-276, 1962. 8. HAGEMAN, J. H. and N. D. D'Esopo and W. W. GLENN. Tuberculosis of the Pericardium. New Engl. J. Med., 270:327-332, 1964. 9. American Thoracic Society. The Present Status of Skeletal Tuberculosis. Am. Rev Resp. Dis., 88:272-274, 1963.
10. CHOFNAS, I. and N. E. SURRETT and H. D. SEVERN. Pott's Disease treated without Spinal Fusion. Am. Rev. Resp. Dis., 90:888-898, 1964. 11. Medical Research Council. A Controlled Trial of Ambulant Out-patient Treatment and In-patient Rest in Bed in the Management of Tuberculosis of the Spine in Young Korean Patients on Standard Chemotherapy. J. Bone and Joint Surg., 55:678-697, 1973.
