This case study follows the progress of a patient with a large necrotic neck wound and the challenges this presented for the care teams working in a large charitable hospital in Malaysia.

INTRODUCTION 

Mrs A, a 48 year old housewife, presented at the accident and emergency department with a history of a severe throat pain and fever for one week. On examination she was pyrexial (axillary temperature 38.5°C) and blood pressure was 110/60mmHg. Her tonsils were inflamed and swollen. In addition, she appeared dehydrated, lethargic, emaciated and breathless on movement. 

On further examination, there was a large necrotic ulcer on the back of her neck and two smaller ulcers in the thoracic spinal region. All three ulcers had been covered using a dry gauze dressing to provide protection from further damage.

TREATMENT PLAN

Routine investigations and blood tests were undertaken and Mrs A was admitted as an inpatient. She was diagnosed as having severe agranulocytosis, acute follicular tonsillitis and a neck ulcer. Subsequent results revealed Klebsiella pneumoniae (a gram-negative bacterial infection) (Box 1). 

It was decided to reverse barrier nurse the patient in protective isolation due her poor immune status and to commence intravenous azithromycin (Zithromax).

Forty-eight hours after admission

During the first 48 hours after admission, Mrs A's condition did not show much improvement and she remained continuously febrile. She complained of worsening odynophagia (pain on swallowing) and dysphagia, and was unable to eat. A CT scan showed a retropharyngeal abscess (RPA).

The risk of RPA is especially high in patients who are immunocompromised. They usually develop secondary to direct spread or lymphatic drainage of upper respiratory or oral infections and carry a high risk of airway obstruction. [1]. RPAs are relatively rare in adults, but due to their high mortality and morbidity rate, early recognition of a RPA is important.

Mrs A's condition continued to deteriorate with severe breathlessness even at rest and she was experiencing frequent loose watery stools. She was transferred to the intensive care unit (ICU) where she was intubated and ventilated. A repeat nasoscopy revealed severe laryngopharyngeal candidiasis.

Deterioration of neck ulcer

Mrs A's condition became more stable and she was transferred to the general ward after two days in the ICU.  During assessment by the ward nurses, the large wound on Mrs A's neck was found to have deteriorated and this had developed a large blister with surrounding neck oedema. She was unable to turn her neck from side to side and she felt tightness around the back of the neck. Mrs A was referred by the surgeon to the ulcer care team (UCT).

The UCT is a new facility within the hospital, although at the time it was not operating fully due to financial constraints. However, its existence was known to several doctors, who on occasion, sought specialist wound management advice from the team.