Hot Seat Case # 111: 9 y/o M with acute neck swelling
Posted on: April 9, 2018, by : Jeremy Root
Jeremy Root, MD Children’s National Medical Center
with Emily Willner, MD Children’s National Medical Center
9 y/o previously healthy male visiting from North Dakota with neck swelling. He was seen at an OSH ED in the morning for R jaw and ear pain. Flu and strep swabs were negative, so he was given Zofran for nausea and passed a PO challenge. He represented back to the OSH ED the same day for worsening neck swelling anteriorly and posteriorly. He was transferred to your pediatric ED for possible imaging.
ROS: + recent congestion, fevers, sore throat, + facial rash, denies vomiting, diarrhea, headache
PMHx: none
PSurgHx: T&A and Myringotomy tubes
Social Hx: visiting from out of state
Exam: VS T 37.3, HR 111, RR 18, BP 115/75, SpO2 98% on RA
GEN: well appearing, interactive
HEENT: pharyngeal erythema w/o exudates; hoarse voice, no trismus, no drooling; PERRL, EOMI, normal conjunctiva, no discharge. TMs clear
CV: regular rate and rhythm, no murmurs or gallops, <2 sec cap refill
PULM: lung clear to auscultation, non-labored respirations, equal breath sounds, no stridor
ABD: soft, NT, ND, no HSM
NEURO: developmentally normal, cranial nerves II-XII intact
MSK: normal ROM, normal strength, no tenderness, no swelling
LYMPH: notable gross neck swelling bilaterally, moderate/severe bilateral anterior and posterior cervical lymphadenopathy, R>L, tender to palpation without overlying skin changes, fluctuance, or drainage; no axillary or inguinal lymphadenopathy
SKIN: no pallor, no rashes
You obtain an ultrasound that shows “multiple enlarged lymph nodes in the bilateral deep space of the neck that could represent lymphandenitis. No drainable fluid collections.” CBC has a white count of 26.7 with 75% neutrophils, 5% bands. Monospot is negative. Patient continues to be well appearing with normal RR, O2 sat.
The plan is made to admit to the hospitalist for IV antibiotics given the rapidity of growth, hoarse voice, blood work results and no available PCP for follow up. The patient’s father prefers to take the patient back to hotel and says he will return if symptoms worsen. Despite a thorough discussion of the risks/benefits of admission, the dad is requesting discharge and is about to walk out of the ED with the patient.
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I’m on the fence for a lot of these questions. Sure, the “hoarse voice” is a scary clinical finding, but then again, the patient seems to be in no respiratory distress. I’d like to see a HR < 100 for a 12-year-old, but I'm generally reassured by your exam findings despite the rapidity of the growth. The neutrophilia certainly points toward a bacterial etiology (maybe strep given the reported + rapid strep test), but the bands < 10% is reassuring that the patient is not going to go back to his hotel room and immediately turn septic. I think, depending on my interactions with the family leading up to the disposition, I might be comfortable discharging him on oral antibiotics. It would be one thing if this was the family's first time in the ED, but given that they actually returned to the same ED twice in one day, they're probably overcautious if anything and would (hopefully) bring him back if his symptoms worsened.
In my mind, the differential diagnosis for this child is still broad:
-Infectious Lymphadenitis (viral, mono, toxo, TB, HIV amongst others)
-Malignancy (leukemia, lymphoma)
-Dental Abscess
-Ludwigs Angina
-Parotitis
Thus, the only thing on this list that is a true emergency in my mind is ludwigs angina (which this does not necessarily sound like). So the rest of these can be diagnosed and managed as an outpatient. I agree with Sam, the rapidity of symptoms are indeed concerning but we all have had patients come in with horrible abscesses or cellulitis that “just started today” so I often take the rapidity with a grain of salt.
I find the monospot not a useful test. It can take up to four weeks to turn positive and some children will never develop positivity. I find the antibodies themselves more helpful.
Also, if I am truly worried about the health of a child and that leaving can potentially result in serious health outcomes, I would call security as well as CPS on the family.
Haroon laid out a great differential and thought process for acute, painful onset of bilateral neck swelling.
From the description given of acute onset of bulky bilateral anterior and posterior LAN, a mononucleosis syndrome would be high on my list. The big clue is the degree of posterior lymphadenopathy. His tonsillectomy status would take away the clue of the classic exudative tonsillar plaques.
I would add one thing to the list, which would less typical in this age group but would concern me: retropharyngeal abscess. These can present with complaint of throat pain and voice change, and with notable reactive lymphadenopathy which is often posterior due to drainage of the retropharyngeal space.
ROM of the neck is not mentioned in the case, but this might be helpful in differentiating RPA from reactive nodes. Because of its location just anterior to the cervical vertebra, RPA often causes pain with neck ROM, particularly neck extension. If the infection is more parapharyngeal, it might cause pain with neck rotation also. I would carefully examine ROM of the neck in this child. I’m not sure I’d jump right to CT for RPA (which is often missed on US due to its deep location), but I’d consider a lateral neck XR with the clinical history, labs, and the US result.
So, does he need to be admitted? I personally would, especially given rapid onset and high WBC with hoarse voice. I’d definitely send EBV and CMV titers (and would likely have sent a CMP with initial labs- EBV often causes a mild transaminitis). With the WBC and time course, I’d cover with abx. There isn’t one right answer, but I’d likely choose amp-sulbactam or clindamycin over ceftriaxone in this case.
Ludwig angina is infection the head or neck which spreads to the deep spaces of the floor of the mouth and can cause rapid progression and airway compromise. Classically, the floor of the mouth is firm and full on palpation- this also isn’t mentioned but the pt is verbal and not drooling, which is less typical with Ludwig’s angina. But: check and document an exam of the floor of the mouth.
As for the family wanting to leave: if there was no clinical concern for limitation of neck ROM, floor of the mouth being firm, and the pt had no subjective SOB, no objective findings of airway compromise, no trouble swallowing and was tolerating PO, I would not call security and/or the police. I would try to explore their reasoning for not wanting to be admitted (financial? Travel-related? Care for other children?) to see if there is anything we can address. If they truly wanted to leave despite that, I would give a dose of IV antibiotics, ask them to have 24 hour follow up in the ED, discharge with a prescription for PO antibiotics and allow them to leave. I would probably have them sign AMA paperwork given the information available in this case. It emphasizes to the parent how serious I think the child’s condition might be.
Agree with Emily’s note that you can cover with a 24 hr dose of Ceftriaxone if discharging them.
I am not a fan of having patients/families signing out AMA. Either safe for them to go home (even if not your first choice), or not. Literature does not support that signing out AMA has insurance implications, nor that it would provide much additional beyond clear documentation of discussion re risks and benefits discussed with family.
Hello everyone. I love seeing more fellow responses here and the discussion has been quite rich with a great differential so far. I’d add atypical mycobacterium to the list. He doesn’t sound sick enough to be a Lemierre’s, (jugular vein suppurative thrombophlebitis) but that should be on the list too.
I’ve not seen many Ludwig’s presentations in kids, typically patients are older, diabetic with poor dentition or recent ENT surgery. This is really a cellulitis plus minus abscess. Emily’s documentation tip is spot on: especially with electronic charting make sure to note dental and oral floor exams. Regarding oral floor, a case that presented more dramatically with “hot potato voice” was a pt with a rhabdomyosarcoma to the base of the tongue, which obstructed when it reached critical mass, the other was Ludwig’s in a precocious diabetic pt with a tongue piercing. As for RPA, if you were somewhere without ultrasound or CT I would start with plain films to assess prevertebral soft tissues. “Hoarse voice” is something to specifically ask parents or caretakers about, and you need to hear the patient speak. How to tell this from vocal fry is another conversation.
When I look at the vignette again, agree with assessment: he does not have impending sepsis, and he does not have an airway that I think will obstruct….yet.
I also wouldn’t use an AMA here, Emily rightly notes the family is from out of town so refusal for admission needs a little more inquiry. If I was very concerned, I would give a dose of ceftriaxone, but bring back for re-evaluation. Decadron can sometimes be helpful for pain and swallowing-if he had a dose at the beginning of the evaluation you might see an effect by time of disposition.
I agree with Emily’s thoughts that RPA has to be high on the differential. I also agree that rather than calling Legal or Security, I’d have a frank discussion with the family regarding risks/benefits and better understand their perspective.
However, I’m going to going out on a limb and state that **this child absolutely needs a neck CT with IV contrast**, especially if there is any thought that we may discharge him. The rapidity of onset of symptoms, hoarse voice, elevated WBC, and significant absolute band count (1335) have me concerned, especially since the diagnosis was not clear by US. CT is much better than US in identifying deep neck infections like RPA. And, in this era of “image gently” we are now too afraid of CT-ing a kid when they really need it. RPA’s are a cannot miss diagnosis, with significant morbidity and mortality if they either rupture into the airway or secondarily lead to mediastinitis. A lateral neck X-ray is a good start, but this kid has ongoing pathology in the neck that needs to be better explored and imaged.
Also, the kid definitely needs Ceftriaxone, but I’d add Clindamycin to cover for neck anaerobes.