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MYSTERY NECK

SWELLING IN A
TEENAGER
Karin Lammert, PGY-3
HPI

■ 15yo previously healthy female transferred from RTU for failure to improve on multiple
antibiotics
■ 1 month ago: lump behind her left ear; resolved spontaneously
■ 1 week ago: lump behind L ear returned, along with new tenderness and fevers
– Also had a scabbed lesion on her left scalp which her sister lanced
■ PCP started augmentin
■ After 5 days on augmentin, fevers persisted, presented to ED
– CBC normal, neck CT with diffuse subcutaneous edema = cellulitis; no abscess or
mastoiditis
– Started on PO Keflex, Bactrim, discharged home
HPI, continued

■ Return to ED 3 days later (on Keflex and Bactrim)


– Persistent fevers, vomiting, pharyngitis, worsening L post-auricular swelling
– Labs: WBC 7.4, 34% bands; ESR 53, CRP 16.5; RFA negative, Rapid strep
negative
■ Admitted to RTU
– Started on IV clindamycin
– Remains febrile, malaise, vomiting
– ENT consulted, recommended continued IV antibiotics and monitoring
■ Transferred to wards the next evening
Data summary
Vomiting, malaise,
pharyngitis
Early May: Late May: lump
lump behind returns, tender, June 4:
ear, resolves fever, scalp first ED June 7: June 8:
on its own scab visit ED -> RTU Wards

Augmentin x5 days Keflex, bactrim IV clindamycin

CBC normal WBC 7, 34% bands


CT neck: cellulitis ESR 53, CRP 16.5
RFA negative, Rapid
strep negative
Additional Information
■ Otherwise healthy, UTD on immunizations, no surgeries, no home meds
■ Home: Lives with mom, dad and sister. She is the youngest of 4; two siblings live outside
the home. They live on a farm with multiple animals. Her girlfriend of 2 years, also lives
with them because her home life is difficult.
■ Education: Has been home schooled the past 2 years due to bullying. Doing well with
online classes, plans to graduate on time.
■ Activities: Played softball in school. Enjoys hiking. Likes music and watching Netflix.
■ Drugs: Tried marijuana a few years ago; none since. Denies tobacco, vaping, IV drug use,
cocaine, or misuse of prescription medications.
■ Sex: Identifies as female. Attracted to women. Has a current girlfriend of two years, they
share a bed in the home and are not sexually active. Before her current partner, she
dated but has never been sexually active. Her partner has never been sexually active and
has no history of STDs or HIV, although she does have oral cold sores.
■ Suicide: Mood is down since the death of family member last month and being in the
hospital currently but denies thoughts of self-harm.
■ Safety: Denies sexual abuse, physical abuse and verbal abuse although she was bullied
at school before starting homeschooling.
Exposure history
■ Pets: dogs, cats (no kittens, have had all of them for years; no cat bites/scratches)
■ Animals: chickens, turkeys, goats, horses; helped friends catch a domesticated flop ear
bunny which was in the wild, but she did not hold or touch it (so no bites, scratches, etc.).
No known rodent contact: a rat which was found on imported material from California at
work, she did not come into contact with the rat, but did touch objects it may have
touched.
■ Travel: none outside of the area
■ Visitors: none
■ Insect bites: none known. But there are ticks and flies in the area. Did go camping 4-6
weeks ago.
■ Sister works in healthcare
■ Water exposures: drinks only tap or bottled water; no other freshwater exposure
■ Food exposures: no unpasteurized milk/dairy; no recent game consumption but they do
eat elk occasionally
Physical Exam
GENERAL: Teenager lying awake in bed, appears comfortable
HEENT: moist mucus membranes, clear conjunctiva, tonsillar hypertrophy without
exudate. Diffuse swelling extending from left mastoid process anteriorly to the angle of
the mandible, with <2cm enlarged submandibular lymph node. Tender but without
erythema, warmth, or fluctuance. No palpable lymphadenopathy on the right side of the
neck.
Left parietal scalp has a superficial 1 cm by 2 cm scabbed lesion. Full neck ROM
without tenderness.
CV: normal rate, rhythm, and S1/S2, without murmur or gallop. Pulses appropriate.
Capillary refill time 2 seconds.
LUNGS: clear to auscultation bilaterally, good air flow, no retractions.
ABD: soft, non-tender, non-distended with active bowel sounds and no masses or
hepatosplenomegaly.
EXT: all extremities warm and well perfused. No cyanosis, clubbing, or edema.
Scalp lesion

Left parietal scalp


has a superficial 1
cm by 2 cm ulcer
with flat-topped
papules and
overlying
hemorrhagic
crusts.
Pt summary

■ 15yo previously healthy female with 2 weeks of fever, lymphadenopathy, unilateral


post-auricular cellulitis, malaise, pharyngitis, vomiting, persistently elevated
inflammatory markers, scalp lesion, and failure to improve on multiple antibiotics.
Differential Diagnosis
■ Infectious
– Cellulitis/lymphadenitis: most commonly strep, staph
– Atypical bacterial causes of adenitis: Mycoplasma, cat-scratch disease
(Bartonella henselae)—not endemic to Utah
– EBV
– Less common: Tularemia, plague, anthrax, Brucella
– Systemic or cutaneous mycosis (in immunocompromised)
– HIV (acute retroviral syndrome)
– Syphilis, chancroid
■ Onc: leukemia, lymphoma
■ Rheum/autoimmune: Kawasaki
Hospital course

■ June 9: ESR 65, CRP 13.6


– “persistent fevers and slowly downtrending inflammatory markers are likely
reflective of clindamycin's action as a bacteriostatic agent rather than
bacteriocidal”
– PO clinda has similar bioavailability as IV

■ ??
Diagnosis
■ June 10: started PO Cipro for empiric treatment of tularemia, sent Tularemia IgG and
IgM, Tularemia PCR swab from draining lesion, ID consulted
■ Alerted lab since F. tularensis is a biohazard if grown in the lab
■ Repeat head/neck CT (at the start of cipro treatment) showed improvement in
periauricular inflammation, no occult abscess or infection
TULAREMIA,
A.K.A. RABBIT FEVER
Tularemia
■ Anaerobic gram-negative bacteria Francisella tularensis, highly infectious
■ Transmission:
– Skin contact with infected animals (rabbits, rodents, cats)
– Bites from infected insects (ticks, deer flies)
– Ingestion or inhalation of contaminated water, dust or aerosols (especially
agricultural)
■ Most common in the south central US but cases have been reported in all states
except Hawaii. Most cases occur in rural regions and in summer months.
■ The average incubation period is 3-5 days following infection, with onset of
nonspecific symptoms including malaise, fever, decreased appetite, vomiting,
fatigue, muscle aches, and headache.
Reported cases
of Tularemia
Source: CDC
Reported cases
of Tularemia
Cases in 2016
Tularemia types
1. Ulceroglandular (most common): central eschar and skin ulceration at the site where
the bacteria entered the body, along with tender regional lymphadenopathy.
2. Glandular tularemia has lymph node swelling but no skin involvement.
3. Oculoglandular occurs when bacteria enter the eye and presents with conjunctivitis
and regional lymphadenopathy.
4. Oropharyngeal--Ingestion of contaminated food or water (more common outside of the
United States), causing sore throat, exudative pharyngitis, tonsillitis, mouth ulcers, and
cervical lymphadenopathy.
5. Pneumonic tularemia is the most severe, with dominant pulmonary infection caused
by primary inhalation of contaminated aerosols, or secondary spread of bacteria to
lungs in the bloodstream if the primary source of infection is left untreated.
6. Typhoidal tularemia presents as fever and generalized symptoms without regional
lymphadenopathy or other localizing signs; it is often difficult to diagnose.
Diagnosis and Treatment
■ F. tularensis DNA by PCR
– Antibody testing is less clinically useful as it can take two weeks for titers to
become reliably positive following an infection, and both IgG and IgM can
remain elevated for years following an infection.
– Gram-stain and routine cultures of blood or infected tissues are rarely positive.
■ Early treatment is essential; any suspected cases should be treated empirically
without waiting for confirmatory diagnostic testing.
■ For moderate to severe disease, the preferred agents are aminoglycosides—
streptomycin in adults and gentamycin for children, intravenously, for 7-10 days.
■ In milder cases, oral doxycycline and ciprofloxacin may be used for a 14-day course
of outpatient treatment. Doxycycline is associated with a higher relapse rate.
■ Surgical management may be necessary for drainage of suppurative lymph nodes or
empyemas.
Patient course
■ Discharged on clindamycin to treat presumed group A streptococcus cellulitis, and
ciprofloxacin for possible tularemia.
– At the time of discharge she had downtrending C-reactive protein, improvement
in fevers, and was feeling better.
■ The day after discharge, tularemia PCR confirmed the diagnosis of ulceroglandular
tularemia. Cultures of the wound finalized negative for aerobic bacteria, fungi, and
acid-fast bacilli.
■ Continued on ciprofloxacin and completed a 14-day course of clindamycin with
healing of her scalp lesion and no further fevers.
■ About two weeks after discharge, she developed increasing neck pain; CT scan
identified large necrotic mass in her post-auricular region that required resection by
ENT. Intraoperative wound cultures were negative.
■ She continued on ciprofloxacin for an additional 5 weeks post-operatively (total two
months duration) with full healing of ear wound and return to her normal state of
health.

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