A 54 year old woman with a history of Type II Diabetes and Hypertension presents to the Emergency Department with right-sided neck pain and swelling.  The pain has been worsening over the last 2 days after chiropractic treatment.  Five days ago the patient was lifting something out of a pool and felt a strain in her neck.  After 3 days of aching pain, her sister recommended that she see a chiropractor.  On day 3 of pain she visited a chiropractor and had her neck manipulated, which consisted of deep tissue massage and “cracking her neck”.  No injections or acupuncture. From that time until ED presentation, the patient noted worsening pain and swelling to her right neck.  Over the last 1-2 days the patient has also had generalized body aches.  No fevers or chills. No headaches, no speech changes, no vision changes. No focal weakness or paresthesias. No nausea, vomiting, or diarrhea. No chest pain or dyspnea. She notes difficulty with walking, which she attributes to pain in her neck. No dizziness or vertigo.  The patient took Motrin and Alleve without relief of symptoms.

Physical Exam:

Vitals: T: 37.2, BP: 127/82, P: 122, RR: 20, Pulse Oximetry: 98%

General: Mildly uncomfortable, no acute distress

HEENT: Pupil equal and reactive, EOMI, moist mucus membranes, normal oropharynx, TM’s clear bilaterally

Neck: Tender soft tissue edema to the right posterior-lateral neck, indurated, approximately 3cm x 4cm, non-pulsatile

Cardiovascular: Sinus tachycardia, no murmurs, equal distal pulses, no edema

Respiratory: Lungs clear bilaterally, no wheezing, rhonchi, or rales

Abdomen: Soft, non-tender, non-distended

Extremities: No edema or cyanosis

Neurologic: CN II-XII intact, 5/5 strength in all 4 extremities, no gross sensory deficit, normal finger to nose, no pronator drift

Skin: warm and dry

Labs:

WBC: 14.1                                          Sodium: 126                          ESR: 80

Hemoglobin: 13.9                              Potassium: 3.5                       CRP: 35.5

Hematocrit: 40.2                               Chloride: 84

Platelets: 168                                                CO2: 26

Neutrophils:   69%                            BUN: 36

Band Neutrophils: 9%                      Creatinine: 1.32

Lymphocytes:            9%                             Glucose: 371

Monocytes: 11%                               AST: 62

Myelocytes: 1%                                 ALT: 126

Promyelocytes: 1%                           Alk Phos: 296

DIAGNOSIS:  Paraspinal Neck Muscle Abscess

The CT of the neck shows nonspecific air density within soft tissue and muscular edema in the posterior elements of C2-3.  The patient was started on broad-spectrum antibiotics and admitted to the hospital. The patient later became febrile and her blood cultures grew pan-sensitive Methicillin-sensitive Staph aureus.  On the day after admission, Interventional Radiology drained 5ml of frank pus from the area of swelling to confirm the diagnosis of neck abscess.  

The majority of neck infections are odontogenic or tonsillar in origin.  Most infections are polymicrobial, including gram positive, negative and anaerobic species. The responsible bacteria are usually normal oral flora that become more virulent and invasive when normal physiologic barriers are broken. 

Minor musculature and fascial injuries are a potential chiropractic side effect that can form a nidus for infection.  The injury to the muscle and fascia has a similar pathophysiology to the force that causes intimal injury in arterial dissection.  Our patient’s history of diabetes, which puts her at a relatively immunocompromised state, put her at higher risk for infection. 

Pearls:

Neck infections are usually polymicrobial and should be treated with broad spectrum antibiotics 

Minor non-penetrating neck trauma has the potential to cause muscle damage that can be a nidus for infection