International Journal of Pediatric Otorhinolaryngology 73 (2009) 18241827

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Case report

Bacteremic methicillin-resistant Staphylococcus aureus deep neck abscess

in a newbornCase report and review of literature
Oana Falup-Pecurariu a, Eugene Leibovitz b,*, Carmen Pascu a, Cristian Falup-Pecurariu c
a

Department of Pediatrics, Childrens Hospital, Faculty of Medicine, Transilvania University Brasov, Romania
Pediatric Infectious Disease Unit, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
c
Department of Neurology, Emergency Teaching Hospital, Transilvania University Brasov, Romania
b

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 22 August 2009
Accepted 6 September 2009
Available online 4 October 2009

We describe an unusual localization of methicillin-resistant Staphylococcus aureus infection (MRSA) in a

very young newborn. A 3-week-old male infant was admitted with fever, irritability, sialorrhea and
stiffed left neck. The ENT examination revealed a deep neck mass and an ultrasound examination
showed diffuse swelling of the left latero-pharyngeal area. A CT examination conrmed a deep neck
abscess with difcult-to-dene borders. Blood and nasopharyngeal cultures returned positive for MRSA.
Treatment was started with intravenous teicoplanin and continued for 14 days with a marked decrease
in abscesss dimensions and improvement in patients general condition. MRSA should be suspected in
the etiology and treatment of neck abscesses in newborns, infants and young children.
2009 Elsevier Ireland Ltd. All rights reserved.

Keywords:
Staphylococcus aureus
Methicillin-resistant
Newborn
Neck abscess

1. Introduction
Deep neck abscesses are unusual in newborns. Information on
this disease at this particular age group is scarce and is generally
included in larger case series reported among older children.
The aim of the present case report is to describe an unusual
localization of methicillin-resistant Staphylococcus aureus (MRSA)
infection in a very young newborn.

2. Case report
A 3-week-old male newborn was admitted at the pediatric
department of Childrens Hospital of Brasov, Romania, with fever,
irritability, decreased food intake, sialorrhea and stiff left position
of the neck during the last 2 days. There was no relevant prenatal
and labor history; the mother did not receive any antibiotic
treatments during the pregnancy or during the delivery. The infant
was born by vaginal delivery after 38 weeks of pregnancy. At
admission, the fever was 39.2 8C; physical examination was
otherwise unremarkable, except mild jaundice. Mobilization of
the neck was painful; stridor was absent. Laboratory examinations
revealed a WBC count of 16,000/mm3 with 75% neutrophils.
Sedimentation rate was 80 mm/h, CRP 4.45 mg/dl and lactic

* Corresponding author at: Pediatric Infectious Disease Unit, Soroka University

Medical Center, P.O. Box 151, Beer-Sheva 84101, Israel. Tel.: +972 8 640 0547;
fax: +972 8 623 2334.
E-mail address: eugenel@bgu.ac.il (E. Leibovitz).
0165-5876/$ see front matter 2009 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijporl.2009.09.008

dehydrogenase was 763 mm/dl. Glucose, electrolytes and liver

function tests were normal. Total bilirubin was 3.5 mg/dl (indirect
2.7 mg/dl). A lumbar punction was not performed. The ENT
examination showed a deep left neck mass and an ultrasound
examination revealed diffuse swelling of the whole left lateropharyngeal area; no pharyngeal pouch or dental focus of the
infection could be detected. The parents refused a diagnostic/
therapeutic puncture of the abscess. A computed tomography (CT)
imaging was performed on the second day of admission (Fig. 1) and
revealed a left latero-pharyngeal collection. Nasopharyngeal and
blood cultures were positive for MRSA. The organism was not
susceptible to amoxicillin/clavulanate and susceptible to clindamycin, vancomycin and teicoplanin. Treatment was started with
intravenous teicoplanin for 14 days with rapid improvement in the
clinical condition and a decrease in the abscess dimensions. A CT
performed on day 19 of hospitalization showed a marked
reduction of the swelling area. The patient was discharged after
29 days of hospitalization in good clinical condition and without
any ndings in the neck examination.
3. Discussion
Our case report presents a 3-week-old newborn with no
previous underlying conditions that developed a deep neck abscess
and bacteremia due to community-acquired MRSA. The infant was
hospitalized due to fever and stiffed left neck and a CT of the neck
revealed the deep neck infection. The patient was successfully
treated with intravenous teicoplanin and recovered completely.
We recommend that MRSA should be suspected in the etiology and

Table 1
Deep neck abscesses in infants and children (review of the literature).
Study years

Age at diagnosis

Clinical presentation at diagnosis

Localization of abscess

Pathogen isolated

Antibiotic
Rx. alone

21991 (31)

19541990

10 (32%) <6 months;

3 neonatesa
Mean 7.8 years;
16 (14%) <1 year

More neck swelling and stridor

in children <1 year
Peritonsillitis ! tonsillitis all;
retro/parapharyngeal ! URTT
(63%); buccal ! dental infection
(67%); trismus (36%)
12 (30%) airway obstruction
(75% <36 months); neck mass
(79%); trismus (18%)
Neck swelling (92%);
lymphadenopathy (68%);
rhinorrhea (36%)

Retropharyngeal

Gram () + anaerobes (38%);

S. aureus (25%); Klebsiella (13%)
b-Hemolytic strep. (18%); S. aureus
(18%); B. melaninogenicus (17%);
H. parainuenzae (14%)

5 (16%)

1995

(117)

19861992

41997 (39)

19861995

59% <36 months

52002 (25)

19891999

All <9 months;

mean 5.6 months

62003 (80)

19922001

Mean 4.9 years

(3 months14 years)

72003 (11)

19992001

4 months8.7 years

82004 (169)

19891999

4.1 years (2 months

18 years); 33 (20%)
<1 years

92004 (68)

19901999

Mean 5 years
4 months, 15 months,
20 months, 23 months
Mean 5.4 years;
66% <6 years

2005

(4)

20012002

2005

(54)

19871999

10

11

122006 (53)

19992004

88% <5 years

in 20022004

132008 (64)

20022006

Mean 44.2 months

72% <4 years

Cellulitis and abscess (n = 80):

fever (58%), limitation of neck
motion (44%), sore throat (38%),
neck pain (34%), neck swelling (19%)
Neck immobility (100%); neck
tenderness (82%); oropharynx
fullness (54%); fever (45%);
trismus (9%)
Neck mass (91%); fever (86%);
cervical adenopathy (83%); poor
intake (66%); neck stiffness (59%)

Fever (88%); sore throat (54%);

neck swelling (51%); torticollis (38%)
Neck swelling (all); leukocytosis (3)
Sore throat (76%); fever (65%);
torticollis (37%); dysphagia (35%);
neck mass (31%)
Not mentioned

Neck mass (97%); fever (55%);

poor intake (13%)

Peritonsillar (49%);
retropharyngeal (22%;)
submandibular (14%);
buccal (11%); 5 Ludwigs angina
Retropharyngeal (82%);
parapharyngeal (10%); both (8%)

25 (21%)

b-Hemolytic strep. (24%);

a-hemolytic strep. (18%)

18 (46%)

S. aureus (80%); Group A strep (4%);

no growth (16%)

None

All abscesses + cellulitis (n = 27):

S. pyogenes (22%), Prevotella (15%)

39/80 (49%)

Lateral retropharyngeal (64%);

retropharyngeal (27%);
submaxilar retropharyngeal (9%)

Not mentioned

10/11 (91%)

Retropharyngeal or
parapharyngeal (49% in
<1 year vs. 21% in >1 year);
anterior or posterior triangles
and submandibular or submental
regions more affected in <1 year
Retropharyngeal (all)

<1 year: S. aureus (79%) vs. Group A

strep (6%); >1 year: Group A strep
(29%) vs. S. aureus (16%)

All surgery

Not mentioned

51/68 (75%)

Deep neck

Methicillin-resistant S. aureus in all 4

None

Retropharyngeal (85%);
parapharyngeal (11%); both (4%)

Streptococcus spp. (50%);

S. aureus (30%); anaerobes (15%)

17/54 (31%)

Ant. triangle (36%); post. triangle

(21%); parapharyngeal (15%);
submental (9%)
Submandibular (38%); post.
triangle (25%); parotid (13%);
retro/parapharyngeal (8%)

S. aureus" from 40% (19992001) to

58% (20022004); CA-MRSA"
from 0% to 64.7%
S. aureus (48%); Streptococcus spp.
(13%); atyp. mycobacteria (5%)

None

Ant. triangle (32%);

parapharyngeal (20%);
retropharyngeal, post. triangle
(12% each)
Retropharyngeal (62%); lateral
pharyngeal (38%)

O. Falup-Pecurariu et al. / International Journal of Pediatric Otorhinolaryngology 73 (2009) 18241827

Ref. (no. patients)

All surgery

Youngest = 6 days age at admission.

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Fig. 1. CT-scan without contrast agents. Right lateral cervical large mass that begins
from the right supraclavicular region and spreads into the pterigopalatin area. The
described mass has solid densities and appears discrete and not homogenous; it has
not a good delimitation form the surrounding structures. The described lesions have
a mass effect over the nasopharynx through parapharyngeal development and a
smaller degree retropharyngeal.

treatment of neck abscesses in newborns, infants and young

children.
In 210 adults hospitalized during 19811998 [1], the most
common causes related to occurrence of neck abscesses were
dental infection (43%), intravenous drug abuse (12%) and
pharyngotonsillitis (6%). Streptococcus viridans was the most
common pathogen (39% of positive cultures), followed by
Staphylococcus epidermidis (22%) and S. aureus (22%). Lateral
pharyngeal (43%), submandibular (28%) and retropharyngeal
(12%) spaces were the most common locations of the infections;
Ludwigs angina was reported in 17% of the patients.
The most relevant studies in the English literature since 1990 on
deep neck abscesses in very young children (including neonates)
are summarized in Table 1 [213]. In children younger than 1 year
of age, the typical clinical presentation at diagnosis included fever,
poor oral intake, neck or pharyngeal swelling, limitation of neck
movement, stridor, cervical lymphadenopathy and rhinorrhea
[2,4,5]. The initial clinical picture was of an upper respiratory
infection with a mean duration of symptoms between 3.8 and 4.3
days [2,4]. The most common locations of the abscesses were
retropharyngeal, parapharyngeal, anterior triangle, posterior
triangle and submandibular [213]. Airway obstruction requiring
immediate transfer to the operating room and intervention to
secure the airway was reported in young children <36 month old
[3].
Most studies have established S. aureus and group A streptococcus as the predominant pathogens in these infections, but
properly performed cultures revealed also anaerobic organisms
[11,14]. Coticchia et al. [8] reported that children younger than 1
year were infected more frequently with S. aureus than with group
A streptococcus and this relationship reverses in children older
than 1 year. A major increase in the number of neck abscesses
caused by MRSA (mostly community-acquired) has been recently
described, partially explained by presence of risk factors as
prolonged antibiotic exposure, day-care attendance and household
contacts with known MRSA cases [10,12]. Lessa et al. [15] analyzed
recently 975 cases of late-onset (after 3 days of age) MRSA
infections occurring in 149 neonatal intensive care units I the
United States during 19952004. The authors reported a 308%
increase (shown in all birth weight categories) in the incidence of
MRS infection/10,000 patient-days, from 0.7% in 1995 to 3.1 in
2004. Bloodstream infections, pneumonia, conjunctivitis, skin and
soft tissue infections, lower respiratory tract infections excluding

pneumonia and surgical site infections (31%, 18%, 17%, 14%, 8% and
4%, respectively) represented the most commonly diagnosed
entities.
While beta-lactamase stable penicillin or cephalosporin antibiotics may be the correct choice in many cases, the increased rates
of isolation of community-acquired MRSA may require the
empirical use of clindamycin or other antibiotics with proved
efcacy against this pathogen like vancomycin or linezolid (not
licensed for neonatal use). Teicoplanin, a drug with good activity
against Gram-positive organisms (including MRSA) may also
represent an attractive choice by its good penetration into a wide
variety of tissues and prolonged half-life allowing an once-daily
administration [16].
An old and still valuable diagnostic tool for the diagnosis of
retropharyngeal abscess is the lateral neck lm (88100%
sensitivity) which helps localizing the process to the neck and
retropharynx [4,17,18]. Today, neck CT with contrast is considered
as the diagnostic tool of choice in diagnosing neck abscess with a
sensitivity of 94% [5]. The classic aspect of neck abscesses on CT
examination is ring enhancement around non-enhancing central
density consistent with uid. The use of contrast-enhanced CT
examinations provides information regarding abscess size, location, differentiates between abscess and cellulitis and establishes
the relative position of the great vessels for safe and successful
transoral drainage [7].
Treatment options of neck abscesses are antibiotic therapy only
or immediate surgical drainage of the abscess accompanied by
antibiotic therapy [18]. Our neonate achieved a rapid improvement
in neck tenderness and mobility and complete resolution without
complications or recurrence with intravenous therapy alone.
However, the majority of infants and children reported in the
literature were treated with immediate drainage of the primary
focus and parenteral antibiotics (Table 1). In addition to the
opportunity to obtain the culture and sensitivity of the offending
pathogen (which could be critical in the present era of increased
resistance to antibiotics of the main etiologic agents, particularly
MRSA), surgical drainage may be needed in order to overcome the
immaturity of the infant immunity system, to treat recalcitrant
infections and to prevent severe complications like descending
mediastinitis [10].
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