A previously healthy 56-year-old male patient was admitted to the Otorhinolaryngology Department with a 5-day history of febrile sense and neck swelling with swallowing difficulty. At admission, he was alert, and his vital signs were stable except for a high fever, which was 39.2°C, along with a sore throat; he was admitted to the Otorhinolaryngology Department. However, there was no focal infection in fiber-optic laryngoscopy, and due to the focal neurological sign of a stiff neck, he was transferred to the Neurosurgery Department. On neurological examination his motor power and sensation were intact. Hematological investigation revealed leukocytosis with a total white blood cell (WBC) count of 12.760/μL, elevation of his erythrocyte sedimentation rate, to 62 mm/hr (normal range, 0–20 mm/hr), and C-reactive protein, to 13.2 mg/dL (normal range, below 0.5 mg/dL). To rule out pyogenic meningitis, a lumbar cerebrospinal fluid (CSF) analysis was performed. The color of the CSF was purulent yellowish (
Fig. 1). Lumbar CSF analysis revealed 2,937 WBC cells/μL (poly:mono, 87%:13%) with a glucose level of 31.8 mg/dL, and protein level of 232.9 mg/dL. A computed tomography (CT) scan of the cervical spine demonstrated sparsely scattered gas in the prevertebral space of C4–5 and intraspinal canal of the C4–5 interspace (
Fig. 2A). Magnetic resonance imaging (MRI) with gadolinium enhancement revealed an epidural abscess with air bubbles in the anterior aspect of the central spinal canal of C4 and C5, compressing the spinal cord and causing a large amount of retropharyngeal abscesses in the prevertebral space of C1 through C7 (
Fig. 2B). Due to its ventral location in the epidural space, the patient underwent open pus and irrigation following gram-stain culture. A yellowish purulent material was identified and retropharyngeal abscess was drained via anterior approach. CSF cultures showed the growth of gram-positive
Streptococcus anginosus and
Streptococcus constellatus.
S. anginosus was also isolated from retropharyngeal abscess. According to an antibiotics susceptibility test, he was given Augmentin (GlaxoSmithKline. Middlesex, UK), Vancomycin (CJ pharmaceuticals, Seoul, Korea), and Metronidazole (CJ pharmaceuticals). Despite aggressive fluid and antibiotic therapy, he did not respond to treatment, in fact, his symptoms worsened. 10 days after admission, the patient’s level of consciousness deteriorated gradually to a drowsy state and showed tetraparesis at GIII/GIII. Brain MRI and magnetic resonance angiography with gadolinium enhancement showed no visible pathological enhanced lesions except for mild hydrocephalus. Cervical MRI with gadolinium enhancement revealed an aggravated high signal intensity of the spinal cord at the level of C5 through T1, suggesting spinal cord dysfunction with a remaining ventral epidural abscess pocket (
Fig. 3). At this time, the patient’s body temperature was 39.8°C. WBC count steadily rose to 18.295 cells/μL, heart rate to 120 beats/min, respiratory rate to 24 breaths/min, and arterial CO
2 tension to 26 mmHg, which indicated a septic condition. He was transferred to Infectious Diseases Department. On the 60th day of hospitalization, at the end of the prolonged antibiotic treatment, MRI revealed a marked regression of the lesions compared to the previous MRI, but little clinical improvement (
Fig. 4). He was awake, alert, and oriented, but his muscle strength and occasional urinary incontinence were not improved. He was not able to walk by himself due to the flaccidity of both feet. Deep tendon reflexes were also persistent appeared in the lower extremities.