PC1192: An Evolving Neck Mass in the Context of covid-19 Infection

Introduction: As of April 2022, there have been over 12 million reported cases of the coronavirus disease 2019 (COVID-19) in children with a rate of 17,095 cases per 100,000 children in the population. Although there is a relatively low mortality from acute SARS-CoV-2 infection in children, complications from the infection have been widely reported. One potential complication that we present with our case is a large retropharyngeal abscess in a pediatric patient.

Case Description: An 18 month-old female presented to the emergency department from her pediatrician’s office with six days of fever, abdominal pain, and three days of vomiting with decreased oral intake.
Laboratory studies demonstrated a leukocytosis with WBC count of 19.7 and CMP with sodium of 135. CRP was elevated at 49.3 and ESR elevated to 97. An ultrasound evaluating for intussusception was negative.
In the emergency department, the patient had a respiratory viral panel which was positive for SARS-CoV-2.
She was subsequently admitted to the hospital for IV hydration in the setting of poor oral intake and continued with malaise and daily fevers. On day two of hospitalization, the rounding team noticed new onset cervical lymphadenopathy, and on day three of hospitalization she subsequently developed audible stertor. Given these findings and continued fevers, a CT of the neck was performed. The scan demonstrated a peripherally enhancing collection, measuring 5.3 x 3.3 x 5.4 cm (AP x TR x CC) centered in the left retropharyngeal space. Otolaryngology was consulted and performed emergent transoral drainage of the abscess. The patient was started on Vancomycin and Unasyn postoperatively, tolerated diet advancements, and was discharged on oral Clindamycin.

Discussion: This patient presented during the Omicron wave of SARS-CoV-2, and as such more was known about the general course and complications of the virus in pediatric patients. However, there remained difficulty in evaluating between the differentials of prolonged course of viral illness with reactive lymphadenopathy, incomplete Kawasaki disease, or neck abscess. The decision to obtain advanced imaging was ultimately delayed until the onset of audible stertor with increasing lymphadenopathy, giving the confounding SARS-CoV-2 infection. The lesson learned by the primary team in the care of this patient centered around cognitive anchoring in the context of the diagnostic fog of a global pandemic.

Conclusion: To the best of our knowledge this case represents the first description of a retropharyngeal abscess causing mass effect on the adjacent airway during SARS-CoV-2 infection in a pediatric patient. Although patients may have prolonged fevers with SARS-CoV-2 infection, it remains important to thoroughly evaluate for other potential etiologies of fever.