Fulminant Tetraplegia in a Patient on Infliximab: A Case of Masked Cervical Spinal Epidural Abscess Presenting With Dysphagia

While spinal epidural abscess (SEA) is a well-recognized neurosurgical emergency, its diagnosis remains a formidable challenge when presenting with atypical symptoms such as dysphagia, particularly in patients under anti-tumor necrosis factor (TNF) therapy. This report describes a critical diagnostic trap: a fulminant cervical SEA in a 59-year-old male patient treated with infliximab for ankylosing spondylitis. Despite being afebrile and neurologically intact upon admission, laboratory investigations revealed a massive inflammatory syndrome (C-reactive protein: 282.9 mg/L). His condition rapidly progressed to sudden tetraplegia during diagnostic imaging. MRI confirmed C3-C4 spondylodiscitis with a massive prevertebral and spinal epidural abscess causing critical cord compression (5 mm residual canal). The patient underwent emergency C3-C4 anterior discectomy and abscess drainage. Despite the successful eradication of the methicillin-susceptible Staphylococcus aureus (MSSA) infection, the patient suffered permanent neurological deficits. This case highlights the potent masking effect of anti-TNF therapy on systemic inflammatory signs and the diagnostic challenge of SEA presenting as dysphagia. It underscores that in immunocompromised patients, the absence of fever must not rule out severe infection when neck pain and elevated inflammatory markers are present. Clinicians must maintain a low threshold for emergency MRI, as the therapeutic window for intervention is exceptionally narrow once fulminant neurological deficits manifest.