Acute Retropharyngeal Edema/Phlegmon with Blood Cultures Positive for Gram-Positive Cocci and Severe Rhabdomyolysis: A Case Report

Abstract

Background: Acute retropharyngeal inflammation is an uncommon but potentially life-threatening condition because rapid progression can compromise the upper airway. Rhabdomyolysis associated with bacterial infection is also uncommon and may be complicated by acute kidney injury. The role of sodium bicarbonate for routine prevention of rhabdomyolysis-associated kidney injury remains uncertain. Case Presentation: An 18-year-old previously healthy woman presented with a 24-hour history of midline neck swelling, severe throat pain, dysphagia, progressive dyspnea, fever, and bilateral lower-limb cramps. She was febrile (39.7 °C), tachycardic (120 beats/min), hypotensive (84/60 mmHg), and tachypneic (29 breaths/min), with a bulging posterior pharyngeal wall. Laboratory testing showed leukocytosis (25,400/µL), creatine kinase (CK) 139,707 U/L, urine myoglobin 967 ng/dL, aspartate aminotransferase 3,970 U/L, alanine aminotransferase 539 U/L, and serum creatinine 0.8 mg/dL. Blood cultures were reported as positive for gram-positive cocci; species identification and susceptibility data were not available. Contrast-enhanced computed tomography demonstrated a non-enhancing hypodense retropharyngeal process extending from C1 to C4, interpreted as edema/phlegmon rather than a discrete drainable abscess. Management included early tracheostomy for airway protection, empirical intravenous linezolid and meropenem followed by ceftriaxone, intravenous normal saline, and sodium bicarbonate for urinary alkalinization. CK declined to 15,270 U/L at 72 hours and 6,250 U/L at 96 hours. Renal function was documented as normal at discharge, and renal replacement therapy was not required. She was discharged on day 10 with a plan to complete a total 14-day antibiotic course. Conclusion: This case highlights the coexistence of acute retropharyngeal infection/inflammation, blood cultures positive for gram-positive cocci, and severe rhabdomyolysis. Early airway protection, treatment of the infectious process, isotonic fluid resuscitation, and serial monitoring of renal function and electrolytes were central to management. Because sodium bicarbonate was administered concurrently with these interventions, the favorable renal outcome cannot be attributed to urinary alkalinization.