Consultant: Pediatrics Consultant 360

A Rare Cause of Neck Pain and Headache


James F. Buscher, MD; Ravi S. Samraj, MD; Judy F. Lew, MD; Bahareh E. Keith, DO, MHSc; Michele N. Lossius, MD; William O. Collins, MD; and Kathleen Ryan, MD


Buscher JB, Samraj RS, Lew JF, Keith BE, Lossius MN, Collins WO, Ryan K. A Rare Cause of Neck Pain and Headache. Consultant for Pediatricians. 2017;e11.

An 8-year-old boy presented with a history of 3 weeks of progressively worsening headache and neck pain, prior to transfer to our institution. Other than the 3 previous weeks of pain, he reported no prior history of headaches or neck pain. His parents had initially felt he was just “sleeping wrong,” but a local emergency department (ED) evaluation had raised concerns of meningitis on day 4 of the boy’s illness, The boy underwent a lumbar puncture in the ED, with normal results. He was diagnosed as having muscle spasms, and diazepam was prescribed.

However, the boy’s symptoms persisted after discharge from the ED, and his pediatrician at follow up had diagnosed streptococcal pharyngitis and prescribed a 10-day course of amoxicillin. At this time, the boy had no nausea, vomiting, or focal neurologic signs, and his pain was localized to the back of the neck at the base of the skull. He reported having subjective low-grade fevers that he had treated with acetaminophen and ibuprofen and that were somewhat relieved by warm showers. However, due to persistent headaches and neck pain, the boy was directly admitted to his local hospital after visiting his pediatrician for a third follow-up visit.  At that time he underwent a computed tomography scan of the head, and results showed a low-density area to the posterior aspect of the nasopharynx measuring 1.9 cm × 2.9 cm. He was then transferred to our institution, where laboratory tests and magnetic resonance imaging (MRI) were ordered.

The results of laboratory tests revealed C-reactive protein of 94.6 mg/L (reference range, 0 to 4.9 mg/L), erythrocyte sedimentation rate of 63 mm/h (reference range, 0 to < 20 mm/hr), and white blood cell count of 12,000 cells/mm3 (reference range, 4500 to 13,000 cells/mm3) without left shift. Nasopharyngeal MRI (Figures 1A-1B) revealed skull base osteomyelitis with a relatively discrete abscess cavity formed in the clivus without any other anatomic abnormalities. No other sources of infection were appreciated.

Clivus infection prettreatment

Figures 1A and 1B. Pretreatment, sagittal view and axial view. 

The otolaryngology and neurosurgery departments were consulted, and antibiotics were delayed pending surgery for biopsy since the patient was stable without fever, had appropriate mentation, and had no focal neurologic signs.

Forty-eight hours after admission, a pediatric otolaryngologist was able to perform a functional endoscopic sinus surgery with aspiration of purulent material, with possible cause of infection from the sphenoid sinus. Cultures were obtained, the patient was started on ceftriaxone and clindamycin, and the aspirate grew microaerophilic Streptococcus species. As per protocol at our institution, no sensitivities were provided.

The boy was discharged on hospital day 11 with a peripherally inserted central catheter (PICC) line, and he completed a total of 4 weeks of intravenous (IV) ceftriaxone and clindamycin before transitioning to oral cefdinir and clindamycin to complete a total of 6-8 weeks of antibiotics.  . After 2 weeks of oral antibiotics, his inflammatory markers were within normal range and antibiotics were discontinued. An MRI with and without contrast was conducted 4 months posttreatment and revealed resolution of the abscess and new bone formation of the clivus (Figures 2A-2B).

Clivus infection posttreatment

Figures 2A and 2B. Posttreatment, sagittal view and axial view.

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