Retropharyngeal abscess as a paradoxical reaction in a child with multi-drug-resistant tuberculosis.

Paradoxical reactions (PRs) are exaggerated inflammatory responses owing to recovery of cellular immunity following initiation of anti-tuberculous therapy (ATT). The presentation is worsening of pre-existing symptoms or development of new lesions. A 14-year-old girl with multi-drug-resistant tuberculosis developed a recurrent asymptomatic retropharyngeal abscess while on ATT. She required multiple aspirations of the abscess. Xpert MTB/RIF detected Mycobacterium tuberculosis from the aspirate which was resistant to rifampicin; culture was negative. Following aspirations of the abscess, continued ATT and a 2-month course of corticosteroids, she remains well and has gained weight. A retropharyngeal abscess presenting in the form of a PR has not been reported previously in adults or children.

Retropharyngeal abscess after chemotherapy.

Chemotherapy increases susceptibility to infection due to the effect on cell-mediated and humoral immunity. Retropharyngeal abscess is a serious head and neck infection that rapidly progresses from toxicity, whether the patient is neutropenic or not. The risk should be carefully assessed with any chemotherapeutic agent, especially docetaxel.

Retropharyngeal abscess in the setting of immune modulation for rheumatoid arthritis.

EDUCATIONAL OBJECTIVE: At the conclusion of this presentation, the participants should be familiar with the management of serious head and neck infections occurring inpatients on biologic agents for rheumatoid arthritis. OBJECTIVES: Present a case of retropharyngeal abscess managed in a patient on abatacept, a T cell immune modulator, for rheumatoid arthritis. Review the literature on the relationship between biologic agents for rheumatoid arthritis and head and neck infections. STUDY DESIGN: Case report. METHODS: Retrospective case review including a review of the relevant literature. RESULTS: The case of a 62-year-old woman with retropharyngeal abscess is presented. Her medical history was significant for rheumatoid arthritis treated with abatacept, a T-cell immune modulator. She presented with progressive odynophagia and neck pain, and a computed tomography scan revealed large retropharyngeal abscess extending to the superior mediastinum with bilateral pleural effusions. Transcervical incision and drainage was performed and infectious disease consultation was obtained. Full recovery was achieved after a month long course of intravenous antibiotics. CONCLUSIONS: Biologic agents that achieve selective immune modulation have revolutionized the treatment of rheumatoid arthritis. However, there is a small but significant risk of serious infection that accompanies these drugs. Otolaryngologists should be vigilant for signs and symptoms of serious head and neck infection in patients who are on biologic agents for rheumatoid arthritis. Management of these patients must account for their diminished immune response to infection.

Systematic safety follow up in a cohort of 107 patients with spondyloarthropathy treated with infliximab: a new perspective on the role of host defence in the pathogenesis of the disease?

BACKGROUND: Recent studies with infliximab indicate the therapeutic potential of tumour necrosis factor alpha blockade in spondyloarthropathy (SpA). Because defective host defence is implicated in the pathogenesis of SpA, the potential side effects of this treatment due to impact on the antimicrobial defence are a major concern. OBJECTIVE: To report systematically the adverse events seen in a large cohort of patients with SpA treated with infliximab, with special attention to bacterial infections. PATIENTS AND METHODS: 107 patients with SpA were treated with infliximab for a total of 191.5 patient years. All serious and/or treatment related adverse events were reported. RESULTS: Eight severe infections occurred, including two reactivations of tuberculosis and three retropharyngeal abscesses, and six minor infections with clear bacterial focus. One patient developed a spinocellular carcinoma of the skin. No cases of demyelinating disease or lupus-like syndrome were seen. Two patients had an infusion reaction, which, however, did not relapse during the next infusion. Finally, three patients with ankylosing spondylitis developed palmoplantar pustulosis. All patients recovered completely with adequate treatment, and infliximab treatment had to be stopped in only five patients with severe infections. CONCLUSIONS: Although the global safety of infliximab in SpA is good compared with previous reports in rheumatoid arthritis and Crohn's disease, the occurrence of infections such as tuberculosis and retropharyngeal abscesses highlights the importance of careful screening and follow up. Focal nasopharyngeal infections and infection related symptoms, possibly induced by streptococci, occurred frequently, suggesting an impairment of specific host defence mechanisms in SpA.