Grisel's Syndrome and Covid Infection in Children: Report of Two Cases

Introduction: Grisel syndrome is a rare condition of rotator subluxation of the atlantoaxial joint that is not associated with trauma or bone lesion. It is characterized by acute and painful torticollis with fever, which is a consequence of complicated pharyngitis and tonsillitis. Material(s) and Method(s): We present two girls, aged 5 and 6 years, who developed atlantoaxial subluxation and torticollis during or after infection with COVID. As part of this, a pararetropharyngeal abscess developed. Based on clinical signs, radiological findings, and the course of the disease, Grisel's syndrome was confirmed. One patient had an asymptomatic COVID infection, before the development of Grisel's syndrome, and the other patient had an active COVID infection, during which Grisel's syndrome developed. Result(s): Both patients were treated multidisciplinary: conservatively with antibiotics and surgically, and then physical therapy was introduced along with the Philadelphia orthosis. Both were in constant clinical improvement and did not develop further complications. According to the literature, the Fielding-Hawkins classification describes 4 degrees of this subluxation, and our patients had type 3 at the time of diagnosis. Conclusion(s): Grisel's syndrome is a rare condition and should be suspected in children with painful torticollis after infections or head and neck surgery. The importance of this syndrome for maxillofacial surgeons is in early differential diagnosis, to avoid early and late consequences of undiagnosed pararetropharyngeal abscess and atlantoaxial subluxation and compression of vital structures. Grisel's syndrome needs to be treated multidisciplinary and immediately.

A 5-Year-Old Child with a Deep Neck Abscess Complicated by Laryngeal Obstruction.

Deep neck space infections (DNSI) are defined as infections in the potential spaces and fascial planes of the neck. We show the clinical case of a retro and para-pharyngeal abscess in a healthy 5-year-old child complicated by compression and dislocation of the larynx with marked airway caliber reduction and potentially fatal extension up to the mediastinal aditus. DNSI can occur at any age and, due to its rapid progression, requires immediate treatment in children. In healthy children, concurrent abscesses in separate neck spaces are rare. DNSI recurrence should alert the physician to the possibility of a congenital problem, and if imaging fails, laryngoscopy may be the best diagnostic technique.

PAINFUL CERVICAL INVOLVEMENT and FEBRILE TORTICOLLIS: A FREQUENT SYMPTOM of PIMS

Background: Pediatric Infammatory Multisystemic Syndrome associated to SARS-CoV2 (PIMS) happens 4 to 6 weeks after SARS-CoV2 infection1-2. Its early diagnostic recognition as well as its early management is important to avoid cardiac complications related to this pathology. Objectives: To highlight a frequent symptom in PIMS and improve its therapeutic care. Methods: The JIR Cohort database, an international registry collecting data on patients with pediatric infammatory diseases, was consulted to include patients between 03/15/20 and 12/31/2021. Results: Of the 140 patients in whom a diagnosis of PIMS was retained, we present a series of 38 patients (27%) who presented at diagnosis or during evolution, febrile torticollis or painful cervical involvement. These patients were on average 8.2 years old (0.6-15.2). The proportion of boys was 14 out of 38 (37%). Twenty-four patients out of 33 (73%) were hospitalized in intensive care. Ten patients out of 38 (26%) underwent cervical imaging, 5 (50%) had abnormalities such as collection or infltration of the soft tissues. At the therapeutic level, 27/38 patients (71%) received corticosteroid therapy, 33/38 (87%) immunoglobulins, and 26/38 (68%) antibiotic therapy. Conclusion: PIMS is a pathology with signifcant clinical heterogeneity and severe consequences in case of delay in therapeutic management. In this epidemic context, it is important to consider PIMS in any patient with febrile torticollis, especially if he does not respond to antibiotics.

A Crick in theNeck: Lemierre Syndrome in a 4-year Old Female Presenting as Fever and Torticollis

Introduction: Described by Dr. Andre Lemierre in a 1936 case series of 20 patients, Lemierre Syndrome (LS) is defined as a septic thrombophlebitis of the internal jugular vein (IJV). LS typically begins as an oropharyngeal infection that advances to the IJV through direct extension through the fascial planes of the neck, or indirect lymphatic or hematogenous spread from the peritonsillar vessels. We present a case of LS in a 4-year-old patient who presents much younger than the typical age range of affected individuals, and who recovered well without any longterm sequelae. Case Description: A 4-year-old ex-27 week female presented with a near 3 week history of intermittent fevers and progressive right-facing torticollis. She had multiple interactions with the health care system over her illness course, and was given diagnoses ranging from general viral syndrome to gingivostomatitis and acute otitis media. Around the 2 week mark, her caretaker described her as having developed a “crick” in her neck while consistently favoring a rightward tilt. On illness day 16, she presented to her pediatrician for routine visit, and was noted to have fever, right tonsillar enlargement, and cervical lymphadenopathy, thereby prompting referral to the emergency department. Her physical exam on admission was additionally significant for a 30 degree rightward head rotation, a swollen and tender right sternocleidomastoid, and submandibular lymphadenopathy. She was resistant to active or passive neck rotation due to discomfort, but was able to traverse the midline with coaxing. Laboratory workup was notable for leukocytosis and thrombocytosis with elevated inflammatory markers, as well as mild transaminitis. Infectious serologic workup was negative for: SARS-CoV-2, Bartonella henselae, Bartonella quintana, EBV, and Mycoplasma. Blood culture showed no growth, but was drawn after antibiotics were given. A CT neck with contrast demonstrated intrinsic occlusion vs compression of the right IJV, and ultrasound and MRI confirmed IJV thrombophlebitis. Discussion: LS is typically associated with Fusobacterium necrophorum infection, a gram-negative anaerobe, with incidence estimated to be around 1 to 3.6 per million per year and mortality rate around 5 to 9%. Significant morbidity is often present, due to dissemination of septic thromboemboli, potentially affecting the CNS, bones/joints, and lungs. The typical age range for LS in pediatric patients clusters around adolescence, but infants as young as 6 months of age have been reported. As oropharyngeal infections most often precede LS, it is important to keep this rare but serious infection on any differential. Conclusion: This patient was diagnosed with Lemierre Syndrome. She was treated with an inpatient course of ampicillin/sulbactam before transitioning to oral amoxicillin/clavulanic acid to complete a total of 4 weeks of antibiotic therapy. All elevated laboratory markers normalized prior to hospital discharge, and the patient had complete resolution of symptoms at outpatient follow up.