Case Presentation: A 32-year-old female with a past medical history of substance use, anxiety, and depression presented with one day of facial erythema. The patient reported that she woke up with facial tenderness and swelling. She also had four days of nasal congestion which improved with Nyquil. On physical exam, patient was tachycardic, tachypneic, afebrile, and normotensive. She was noted to have a non-blanching petechial rash on the face and neck (Figure 1). She was also found to have oral ulcers, mandibular swelling, and bilateral conjunctival hemorrhages. There were several laceration marks on both arms and thighs. She presented with mood congruence and expressed concern for her health and well-being. Initial labs were remarkable for tachycardia, tachypnea, and a white blood cell count of 32.2K, associated with an elevated lactate acid. A computed tomography (CT) scan of the face and neck was done to assess facial rash and swelling, which showed retro-pharyngitis with phlegmonous changes, as well as left parotid and submandibular sialadenitis without evidence of a discrete abscess. Empiric broad-spectrum antibiotics with vancomycin, ampicillin-sulbactam, and clindamycin for severe sepsis were started, as well as dexamethasone to prevent airway obstruction. Blood cultures obtained on admission were notable for Staphylococcus epidermidis in one set and Viridans group streptococci in a second set. The lactate and WBC quickly improved, and antibiotics were de-escalated to ceftriaxone and vancomycin, then to cephalexin for a total of ten days. Later in the hospital course, the patient’s therapist contacted the medicine team informing them that patient had attempted to end her life by inhaling cocaine and strangling herself. She woke up the next morning with subsequent facial swelling and a sore throat which prompted her ED visit. After finishing the antibiotic course, the patient was transferred to inpatient psychiatry where she recovered well and was discharged home.

Discussion: Retro-pharyngitis is most commonly the result of an antecedent upper respiratory tract infection (URI) complicated by suppurative deep neck infection. Although rare, blunt trauma has been reported to cause retro-pharyngitis/abscess(1, 2). In our patient, the initial cause of retro-pharyngitis was suspected to be due to a viral URI and severely exacerbated by blunt trauma from strangulation. In the age group years 20-34, suicide remains the second leading cause of death(3). Strangulation is more common in men, while women mostly ingest poison or overdose on medication(4). In a review of 300 cases, 50% of people do not have visible signs after strangulation(5). Petechiae can be seen in the skin, conjunctiva, or other mucosal surfaces in those with signs. The presence of petechiae does not prove strangulation, but in the presence of a clinical history of strangulation, petechiae are a sign of a serious, life-threatening injury(6). In hospitalized strangulation cases, neck injury is seen in 65% of manual strangulation and 25% of suicidal hanging cases. In strangulation survivors, a routine CT neck would be beneficial.

Conclusions: In patients with a history of severe depression and facial petechiae, recent neck strangulation should be suspected, and suicidal ideation should be thoroughly assessed. Retro-pharyngitis is more commonly caused by URI, but can also occur after blunt trauma, such as a near-hanging injury.

IMAGE 1: Figure 1. Facial rash