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Septic Thrombosis of the Internal Vertebral Venous Plexus : A Rare Cause of Neck Pain

An immunocompetent 66-year-old Japanese woman presented at our hospital with a fever and posterior neck pain which had developed 10 days previously. She had hypertension, dyslipidemia and untreated dental caries, but no other comorbidities, recent medical problems, including upper respiratory tract infections, or a family history of thrombosis. On the initial evaluation, she was unable to move her neck to the left side due to severe pain. Blood tests showed significant leukocytosis (white blood cell count, 12,000/μL) and an elevated C-reactive protein level (17.7mg/dL). Computed tomography (CT) revealed thrombosis of the left internal vertebral venous plexus in the upper cervical area (Figure 1), which was subsequently confirmed by magnetic resonance imaging (Figure 2). The patient was hospitalized after two sets of blood cultures were obtained. Empirical treatment was initiated with intravenous ceftriaxone followed by the addition of oral metronidazole on day six, and anticoagulation therapy was simultaneously performed with heparin and warfarin. Enhanced chest and abdominal CT showed bilateral pulmonary nodules with a cavity, thus suggesting septic embolisms. There was no embolism in any other organs and no apparent tumors were identified. Evaluations of protein C, protein S, antithrombin III and anticardiolipin antibodies were not suggestive of a hypercoagulable state, although all measurements were made during the acute phase of the thrombosis on day four. The blood cultures grew Fusobacterium nucleatum on day four, which was later confirmed using 16S rRNA sequence typing. We continued the initial antibiotic therapy (ceftriaxone iv and metronidazole po) until her neck pain was resolved due to the suspicion of a mixed infection,1 and subsequently changed the therapy to oral amoxicillin on day twenty-one. The patient improved clinically with six weeks of antibiotics and