SHM Converge Scientific Abstract ePoster Gallery-A Royal Pain in the Neck: Crowned Dens Syndrome Mimicking Meningitis

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A 58-year-old man with treated HIV, hepatitis C status post liver transplant on cyclosporine, prior Burkitt lymphoma, CKD, atrial fibrillation, and gout presented with 48 hours of fever, headache, and nuchal rigidity after recent dry needling of the neck and back. He also had a swollen, painful right elbow. Because his presentation strongly suggested meningitis, he was admitted and started on broad-spectrum antimicrobials and acyclovir.<br /><br />Initial workup, including lumbar puncture, was negative. Cervical CT and MRI showed calcium deposition around the dens of C2 and pannus formation at C1/C2, findings consistent with crowned dens syndrome (CDS), a rare manifestation of calcium pyrophosphate deposition disease (CPPD). Arthrocentesis of the right elbow revealed intracellular calcium pyrophosphate crystals, confirming pseudogout and supporting the diagnosis.<br /><br />CDS is an underrecognized meningitis mimic that can present with acute neck pain, fever, nuchal rigidity, and elevated inflammatory markers. It is often misdiagnosed, leading to diagnostic delay. In this case, the combination of a high index of suspicion, imaging, and early arthrocentesis allowed diagnosis by hospital day 2.<br /><br />Treatment with prednisone led to rapid improvement and near-complete symptom resolution. Antibiotics were discontinued once infection was excluded. He could not receive colchicine because of interaction with cyclosporine, and NSAIDs were avoided due to CKD and other comorbidities. He was discharged on a short prednisone taper and low-dose prednisone for CPPD prophylaxis.<br /><br />This case highlights the importance of considering crowned dens syndrome when meningitis evaluation is negative but severe neck pain and rigidity persist, especially in patients with risk factors for CPPD. Early spinal imaging can shorten hospitalization and prevent unnecessary treatment.

Asset Subtitle

Lila M. Lehtola

Meta Tag

Author List Henry R. Kramer, Lila M. Lehtola, Matthew Wofford

Category Clinical Vignettes

Concept Crowned Dens Syndrome

Concept Neck Pain

Concept Nuchal Rigidity

Concept Pseudogout

Concept Fever

Distinguished Non-Finalist

Presenter Organization University of Colorado Hospital--Anschutz

Presenting Author Lila M. Lehtola

Track Adult

Keywords

crowned dens syndrome

calcium pyrophosphate deposition disease

pseudogout

meningitis mimic

neck pain

nuchal rigidity

cervical CT

prednisone

arthrocentesis

immunosuppressed patient

Crowned Dens Syndrome

Neck Pain

Nuchal Rigidity

Pseudogout

Fever