Case by Steven Garbin MD, INOVA PEM Fellow

An 11-month-old girl with a history of Diamond-Blackfan anemia presents with fever, a left-sided neck mass, and trouble breathing. The patient’s mother reports the child developed a fever 1-2 days ago (Tmax 101F) for which they have been giving regular antipyretics. Last night she noticed a bump on the left side of the child’s neck. Overnight the child seemed to be breathing more rapidly and working harder to breathe. They went to their hematologist’s office this morning where labs were drawn which showed stable anemia and mild leukocytosis. On exam, wheeze and increased work of breathing were noted, prompting transfer to the ED. No diarrhea, rash, or vomiting. Fully immunized.

VS: T 100.6 HR 156 RR 49 BP 92/67 SpO2 93%

General: Mild/mod respiratory distress as below
HEENT: PERRL. No conjunctival injection. NCAT, clear nasal congestion, no oropharyngeal swelling, L 1-2 cm mobile mass overlying sternocleidomastoid, no associated erythema, multiple shotty cervical nodes, neck supple, no meningismus.
CV: Tachycardic. No murmurs.
Resp: Tachypneic. Subcostal retractions. Scattered wheezes/rhonchi bilaterally.
GI: Abdomen soft, non-tender and non-distended.
Neuro: Alert, age-appropriate. Moving all extremities.
Skin: No rashes.

Antipyretics were given, nasal suctioning was performed and an IV was placed. A DuoNeb was administered with minimal improvement. HFNC was initiated (1.5L/kg at 40% FiO2) with improved work of breathing. Heart rate also improves to the 120s. SpO2 98%

A chest x-ray was performed showing “no pneumonia.” Neck ultrasound shows a 1.4cmx2cm L-sided lymph node with several other lymph nodes in the area which “appear reactive.”

You get off the phone with the hospitalist having secured an admission to your intermediate care unit for HFNC/suctioning with a diagnosis of bronchiolitis. About 30 minutes later the nurse asks you to re-evaluate the patient because she’s concerned after performing her pre-transfer assessment.

When you enter the room, the patient is in more respiratory distress despite HFNC at 1.5L/kg 40% FiO2. You think the left side of her neck appears different/perhaps the mass is larger than before on observation and when you palpate it. You ask the parents if they agree since they have been at the bedside for the entire visit. They are concerned the mass might be larger as well. There is no oropharyngeal swelling. On auscultation of the lungs, you hear inspiratory and expiratory noises.

Your vitals in the room: HR 151 RR 51 SpO2 98% BP 91/65