Cervical Necrotizing Fasciitis With Intractable Hiccups

We report a case of a 61-year-old immunosuppressed man with rheumatoid arthritis on etanercept and past intravenous drug use who presented with intractable hiccups, an unreported feature of cervical necrotizing fasciitis (CNF). He was initially diagnosed with a viral syndrome, but later developed severe sepsis with neck swelling, dysphagia, and ligneous induration. The absence of skin changes, probably secondary to etanercept-induced immunosuppression, hindered diagnosis. Contrast-enhanced computed tomography (CT) scan of the neck indicated CNF accompanied by descending necrotizing mediastinitis (DNM) with gas in the cervical and mediastinal soft tissues. The early surgical debridement, empirical broad-spectrum antibiotics (linezolid, ampicillin-sulbactam), and multidisciplinary teamwork were responsible for a good outcome after delayed diagnosis. Hiccups that can be regarded as a soft sign of phrenic/vagus nerve irritation or hyponatremia caused by sepsis were introduced as another aspect of this disease. This case illustrates the need for a high index of clinical suspicion and the utility of early imaging in immunocompromised patients with atypical presentations. These findings indicate a need for new diagnostic strategies to enhance the outcome of this deadly disease.