An Interesting Case of Nuchal Rigidity

Abstract

A 34 year-old female without prior relevant medical history presented to our emergency room with a two-day history of neck pain, odynophagia and elevated body temperature up to 38.2° C. Her general practitioner had started the patient on antibiotic treatment with ciprofloxacin and referred her to our emergency department for further diagnostic workup and treatment of suspected meningitis. Initial neurological examination revealed neck rigidity and head pain without further focal neurological signs. Body temperature was 37.7 °C, blood analyses revealed a normal leukocyte count (8.900/μl) and normal C-reactive protein (<0.3mg/dl), blood cultures were sterile. Lumbar puncture was without pathological findings (<1 leukocytes/μl, normal levels for glucose, lactate and protein). Cervical magnetic resonance imaging could rule out osseous injury and cervical myelopathy, however a small prevertebral, retropharyngeal fluid collection was visible (Figure 1a-c). This prompted the diagnosis of acute retropharyngeal calcific tendinitis (RCT). This diagnosis was confirmed by conventional x-ray showing the presence of a characteristic amorphous calcification in the retropharyngeal space anterior to the C1-C2 segments (Figure 1d). Treatment with i.v. methylprednisolone (250mg) was started and pain was reduced shortly after the first infusion. The patient was discharged on tapered oral methylprednisolone and non-steroidal anti-inflammatory drug (NSAID) treatment. Symptoms resolved completely within a week.