A case report of quadriplegia and acute stroke from tracking retropharyngeal and epidural abscess complicated by necrotizing fasciitis

Abstract

A 59-year-old male presented to the emergency department complaining of severe posterior neck pain and progressive extremity weakness for 2 weeks. He was found to be quadriplegic with complete sensory and motor deficits at the C5 level and hypotensive. Diagnostic imaging revealed discitis/osteomyelitis at the C5-C6 and C6-C7 vertebral levels with multiple spinal epidural abscesses extending from C5-C7 with resulting severe spinal canal narrowing with cord compression. Imaging also showed a right vertebral artery occlusion, acute right posterior cerebral artery infarct, retropharyngeal abscess, and extensive paraspinal soft tissue myonecrosis. Vasopressors and broad-spectrum antibiotics were started. He was then transferred to a tertiary medical center where he underwent emergent cervical spine decompression surgery with laminectomy from C3-C7, paraspinal soft tissue debridement, and abscess incision and drainage. He suffered a complicated hospital course and despite aggressive treatment developed worsening infectious myelopathy and died in the hospital. This case involves the rare presentation of quadriplegia and acute cerebral infarction associated with necrotizing fasciitis and spinal epidural abscesses that originated from a retropharyngeal abscess. To date, there have been no cases documenting such a phenomenon, and epidural abscess has not been known to cause adjacent necrotizing fasciitis. Furthermore, vertebral artery thrombosis via mass effect from local infection leading to acute embolic stroke has never been reported. This report sheds light on rare sequela of a tracking retropharyngeal and epidural abscess. Prompt recognition, diagnosis, and treatment are vital to maintain infectious source control and preserve neurological function, although many develop persistent deficits.