Cervical Necrotizing Fasciitis With Intractable Hiccups.

Area of Science:

• Infectious Diseases
• Immunology
• Radiology

Background:

• Cervical necrotizing fasciitis (CNF) is a rare, life-threatening soft tissue infection.
• Immunosuppression, particularly from medications like etanercept, can mask typical signs of infection.
• Rheumatoid arthritis patients on immunosuppressants are at increased risk for severe infections.

Observation:

• A 61-year-old immunosuppressed male with rheumatoid arthritis presented with intractable hiccups, a previously unreported symptom of CNF.
• Initial diagnosis of viral syndrome was complicated by the absence of skin changes due to etanercept.
• The patient developed severe sepsis with neck swelling, dysphagia, and ligneous induration.

Findings:

• Contrast-enhanced computed tomography (CT) scan revealed CNF with descending necrotizing mediastinitis (DNM).
• Gas was present in the cervical and mediastinal soft tissues, confirming the extent of infection.
• Prompt surgical debridement and broad-spectrum antibiotics (linezolid, ampicillin-sulbactam) led to a favorable outcome.

Implications:

• Hiccups may serve as an atypical presenting sign of CNF, potentially indicating phrenic/vagus nerve irritation or sepsis-induced hyponatremia.
• This case underscores the importance of high clinical suspicion and early imaging in immunocompromised patients with atypical presentations.
• New diagnostic strategies are needed to improve outcomes for this deadly condition.