Pre-Sternal Abscess associated with Deep Neck Infection

A previously healthy 2-year-old girl presented with a 2-day history of fever and right cervical lymphadenitis. History revealed acute otitis media two weeks ago. Physical examination of the head, neck, and oropharynx revealed hyperemic oropharynx. Her white blood cell count (WBC) and C-reactive protein (CRP) were 15400 109/L and 8.7 mg/L, respectively. The patient was hospitalized with a diagnosis of deep neck infection and empiric antibiotic treatment with sulbactam-ampicillin was started. The blood culture was negative. A pre-sternal mass of 10 cm in diameter was noticed on fifth day of hospitalization [Fig. 1]. The posteroanterior chest radiograph showed air in the soft tissue at the level of right cervical and interclavicular region [Fig. 2 (a), (b)]. Further imaging with contrast-enhanced computerized tomography (CT) of the neck and thorax demonstrated subcutaneous edema and soft tissue swelling with large abnormal air collections suggesting abscess formation from the right cervical region to the anterior chest wall [Fig. 2 (c), (d)]. Due to rapid progression even under antimicrobial treatment, antibiotic therapy was changed to meropenem, clindamycin, and vancomycin in addition to surgical incision and drainage. Twenty milliliter of pus was drained and the culture of the exudate grew Streptococcus anginosus sensitive to vancomycin. Primary immunologic work-up was found to be normal. Patient was discharged home after 15 days of hospitalization. Figure 1: Deep neck infection was located mainly in the right cervical area (a), spreads and ends with a swelling (b) on anterior thoracic wall.