Delayed diagnosis of odontoid peg osteomyelitis with bilateral X and XII cranial nerve palsies

What is it about?

Among cases of vertebral osteomyelitis, which itself is an uncommon entity, involvement of cervical spine is rare. Its presenting features are fever and neck pain but rarely can involve lower nerves. Osteomyelitic disease of first and second cervical vertebra is a diagnostic challenge due to multiple reasons. First due to its proximity to skull base, disease process can produce neurological deficits, attributed to involvement of lower cranial nerves, causing diagnostic uncertainty in localisation. Also, due the unique and complex anatomy of atlanto-axial joint, imaging can be challenging, even with an MRI. Although MRI still remains the main imaging modality. Specific protocol for imaging with a high level of suspicion is required to make the correct diagnosis. Making a diagnosis can be challenging, as images can be difficult to interpret, even with the most reliable imaging modality for spinal diseases like Magnetic resonance imaging. Delay in diagnosis is linked with increased morbidity and mortality. We describe a case of 67 year old lady, who presented with complain of loss of voice, neck pain and fever for 5 days. Despite repeated imaging of neck with CT and MRI, a diagnosis was not reached. As patient’s condition continued to deteriorate, clinical signs of bilateral 10th and 12th cranial nerve paralysis became apparent and lead to a focused work up for base of skull pathology. Discussion with radiologist, helped guide the imaging protocol, which lead to correct diagnosis being made. Treatment was tailored by blood cultures and available images. Temporary immobilization with cervical collar and a total of 12 weeks of antibiotics lead to complete remission.

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