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  Table of Contents    
LETTER TO EDITOR  
Year : 2022  |  Volume : 65  |  Issue : 3  |  Page : 741-743
Primary retropharyngeal tubercular abscess– A rare presentation


Department of Pathology, Maulana Azad Medical College and Associated Hospitals, New Delhi, India

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Date of Submission30-Oct-2020
Date of Decision15-Apr-2021
Date of Acceptance07-Aug-2021
Date of Web Publication08-Jun-2022
 

How to cite this article:
Kumar R, Arora P, Jain SL. Primary retropharyngeal tubercular abscess– A rare presentation. Indian J Pathol Microbiol 2022;65:741-3

How to cite this URL:
Kumar R, Arora P, Jain SL. Primary retropharyngeal tubercular abscess– A rare presentation. Indian J Pathol Microbiol [serial online] 2022 [cited 2022 Aug 15];65:741-3. Available from: https://www.ijpmonline.org/text.asp?2022/65/3/741/351593




Dear Editor,

The retropharyngeal abscess (RA) can be acute or chronic in nature. Acute abscesses mostly occur in children due to local infection from ear, nose, or throat draining to adjacent lymph nodes (LNs), while in adults are often pyogenic secondary to pharyngeal/oesophageal perforation, sepsis in the throat or sinuses, post penetrating injury, endotracheal intubation, endoscopic procedures or foreign body piercing the posterior pharyngeal wall. Chronic RA is rare in immunocompetent adults. Retropharyngeal tubercular abscesses (RTA) are rare, seen mostly in children usually due to spinal tuberculosis (TB).[1]

A 27-year-old male had difficulty swallowing for the last three months. He had no other complaint, no past history of TB or contact; also, he did not respond to antibiotics. He had a nontender posterior pharyngeal wall bulge measuring 1.4 × 1.3 cm in size with a smooth surface. Other local and systemic examinations were within normal limits. Routine hemogram report was within normal limits except high ESR (44 mm/hr) and Monteux test positive (40 mm). X-ray spine and chest were within normal limits. CT scan showed a tri-loculated cystic space-occupying lesion (SOL) in the right retropharyngeal space measuring 2 × 1.6 × 1.4 cm [Figure 1]. Intraoral FNAC from the lesion showed dispersed and clusters of epithelioid cell granulomas in caseating and an acute suppurative necrotic background; Ziehl-Neelsen (ZN) stain for acid-fast bacilli (AFB) was positive [Figure 2]. AFB culture and GeneXpert were positive for TB. The patient was treated with standard anti-tuberculosis therapy (ATT) avoiding surgical intervention; on further follow-up, his symptoms improved with a marked decrease in the size of the lesion.
Figure 1: a: Clinical photograph: Showing Right retropharyngeal abscess. b: CT scan neck: tri-loculated cystic SOL in Right Retropharyngeal space. c: X-Ray neck: antero-posterior, lateral view. d: X-Ray chest: no evidence of tuberculous lesion

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Figure 2: a: FNA smear, showing viable epithelioid cell granuloma. (Giemsa stain x 400). b: FNAC smear, showing degenerated granuloma in a caseous background (Giemsa stain x 400); Inset: Acid fast bacilli (Ziehl-Neelsen stain x1000)

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Tuberculosis is a worldwide major public health concern; the largest number of incident cases were reported in India (year 2012, range 2.0–2.4 million) corresponding to 26% of global cases.[2] Isolated retropharyngeal TB (RTB) presenting as a deep neck abscess without cervical and/pulmonary TB is a rare form of extrapulmonary tuberculosis (ETB) and is potentially deadly. Globally, out of 5.7 million new cases of TB (year 2014), 0.8 million patients had ETB and, up to 10% of these involved head and neck.[3] RTA is uncommon even in endemic regions, is potentially fatal as it can spread to the chest leading to many complications (airway obstruction, mediastinitis, aspiration pneumonia, epidural abscess, jugular venous thrombosis, necrotizing fasciitis, sepsis, erosion into the carotid artery). Primary pharyngeal TB is a diagnostic dilemma; high degree of clinical suspicion, detailed clinical-physical examinations and investigations are mandatory i.e., FNAC, CT scan, and MRI to arrive at an early and accurate diagnosis and, appropriate timely treatment avoiding the spread of the infection and unnecessary surgery. RTA in adults is rare and occurs due to lymphatic drainage to retropharyngeal LNs. Occasionally the abscess may be due to hematogenous spread from pulmonary or ETB, rarely without any evidence of TB elsewhere.[4],[5]

FNAC is a non-invasive, simple, rapid procedure used to diagnose TB and to exclude malignancy mimicking prevertebral abscess.[5] CT and MRI play a great role to assess the type and extent of the lesion damaging important neck structures to search for tubercular focus at other sites before entertaining the diagnosis of primary RTA.

Primary pharyngeal TB (PPTB) is extremely rare even in endemic areas except for a few case reports. Amin et al. reported a case of RTA in a young male and, Lee et al. reported a case of Primary pharyngeal Tuberculosis (PPTB) that was suspected of submucosal tumor; in both cases, there was no cervical spine and pulmonary involvement.[6],[7] Similarly, cases of retropharyngeal cold abscess without Pott's disease of the cervical spine have been reported by other authors also.[1] RTA requires prompt diagnosis and early management to avert its spread and fatal consequences. Clinicians should be aware that aggressive ATT is necessary to prevent further complications.

Although primary RTA is rare, should be considered in cases of chronic retropharyngeal abscess not responding to broad-spectrum antibiotics. Detailed clinico-radiological examination and non-invasive FNAC procedures are mandatory for accurate diagnosis, timely appropriate treatment and to prevent fatal complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.



 
   References Top

1.
Singh J, Velankar H, Shinde D, Chordia N, Budhwani S. Retropharyngeal cold abscess without Pott's spine. S Afr J Surg 2012;50:137-9.  Back to cited text no. 1
    
2.
Glaziou P, Sismanidis C, Floyd K, Raviglione M. Global epidemiology of tuberculosis. Cold Spring Harb Perspect Med 2014;5:a017798.  Back to cited text no. 2
    
3.
World Health Organization. 2014. Global Tuberculosis Report.  Back to cited text no. 3
    
4.
Meher R, Jain A, Sabharwal A, Gupta B, Singh I, Agarwal AK. Deep neck abscess: A prospective study of 54 cases. J Laryngol Otol 2005;119:299-302.  Back to cited text no. 4
    
5.
Ekka M, Sinha S. Retropharyngeal abscess as a rare presentation of pulmonary tuberculosis. Lung India 2015;32:262-4.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Amine C, Amine B, Amal H, Abdelatif O, Nouredine EA, et al. Rare Case ff Tuberculous Retropharyngeal Abscess. Internet J Head and Neck Surg 2009:4.  Back to cited text no. 6
    
7.
Lee KA, Rya KA, Kwon KR, KOO BS. Primary pharyngeal tuberculosis presenting as a submucosal tumour. Int J Oral Maxillofac Surg.2014; 43:1005-7.  Back to cited text no. 7
    

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Correspondence Address:
Rabish Kumar
Flat No: O4/404, Oxirich Avenue, Niho Society, Ahinsha Khand 2, Indiarapuram, Ghaziabad, Uttar Pradesh - 201 014
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_1327_20

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