P3C332: To the Danger Space and Beyond! an Alternative Etiology for Meningeal Signs in a 12-month-old Male

Introduction: The danger space refers to the posterior portion of the retropharyngeal deep neck compartment, extending distally into the posterior mediastinum. It has no specific contents however may serve as a channel for rapidly spreading infections into the thoracic cavity. Infections in this space typically present with a prodromal illness, with or without fever, often accompanied by a sore throat, voice changes, difficulty swallowing, neck swelling, and limited neck motion.

Case Description: A 12-month-old unvaccinated male presents for evaluation of cough, congestion, and 6 days of consecutive fever. He is found to have Influenza A and is admitted for fluid resuscitation. The next day he continues to fever and develops difficulty swallowing. He becomes more tachycardic, tachypneic, and hypoxemic with grunting on exam that worsens on day 3. He is started on empiric vancomycin and ceftriaxone while pursing further workup. On exam he is ill appearing with his head held superiorly to the left. He has right sided facial edema and bilateral submandibular swelling. He has no breath sounds on the right, clear breath sounds on the left, persistent grunting, mild subcostal retractions, and tracheal tugging. His oropharynx is erythematous without exudates, symmetric 3+ tonsillar hypertrophy, and midline uvula. His neck is stiff, although he allows passive movement side to side, he strongly resists neck flexion with a positive Brudzinski’s sign. Laboratory evaluation reveals elevated inflammatory markers (Table 1). A CT neck and chest with contrast was concerning for right sided necrotizing pneumonia and mediastinal abscess extending along the danger space into the right parapharyngeal space (Figure 1). He was taken to the OR for emergent surgical drainage of the abscess. Intraoperative and peripheral blood cultures grew MRSA. He remained on IV vancomycin until discharge when he was transitioned to oral clindamycin to complete a total of 4 weeks of therapy with complete resolution of his symptoms at his follow up visit.

Discussion: Our patient’s apparent meningeal signs were indications of an invasive infection within the danger space. The anatomy of this space allowed for rapid spread into the thoracic cavity and required extensive treatment.

Conclusion: Typical signs and symptoms of a danger space infection may be difficult to identify in infants and toddlers and is often missed until a patient becomes septic. It is important to keep a retropharyngeal abscess on your differential when evaluating patients with neck pain and rigidity because delay of such diagnosis can be life threatening.