A previously healthy 15-year-old female presents to the emergency department (ED) with complaints of right-sided neck swelling, pain, decreased range of motion, and fever for 3 days. She also reports a sore throat and mouth pain with decreased oral intake. She denies any rhinorrhea, shortness of breath, difficulty swallowing, vomiting, or dental pain.
The patient was previously evaluated by her primary care doctor earlier this same week with similar symptoms. She tested negative for mononucleosis and Streptococcus pharyngitis and was prescribed amoxicillin-clavulanate for suspected bacterial lymphadenitis. The parent and the girl report that the symptoms persisted and worsened despite the oral antibiotics. There is no other significant past medical history, family history, or surgical history.
Physical exam and lab tests
Upon arrival to the ED, the patient appeared to be in mild distress, secondary to pain. Her temperature was 98.6°F; pulse, 92 beats per minute; respiratory rate, 18 breaths per minute; blood pressure, 129/96 mm Hg; and oxygen saturation, 99% on room air. Her exam was significant for swelling at the floor of the mouth with no obvious dental caries or sources of infection. The right submandibular salivary gland was enlarged and tender to palpation. No overlying skin erythema was noted. The remaining physical exam was within normal limits.
Blood was obtained for analysis while the patient was in the ED and included a complete blood count, basic electrolytes, and inflammatory markers. Significant laboratory results included a total white blood cell count of 15,040 per mm3 with a differential count including 72% neutrophils. The C-reactive protein was elevated to 39.9 mg/L and erythrocyte sedimentation rate was 24 mm/h. The remaining laboratory values were normal.
Differentials include Ludwig angina, Lemierre syndrome, cervical adenitis, brachial cleft cyst, sialadenitis, and sialolithiasis (Table 1). Ludwig angina is a form of cellulitis of the submental, sublingual, and submandibular spaces. Patients may present with swelling of the lower jaw and neck, mouth pain, and/or inability to open the mouth. This condition often spreads rapidly and can be life threatening due to the potential of upper airway obstruction.1 Ludwig angina is a rare diagnosis in the pediatric population, and because of the unfamiliarity of pediatric providers with the condition, children can potentially experience delay in diagnosis and treatment. This serious condition should be treated with intravenous antibiotic and possibly judicious surgical intervention.1
Lemierre syndrome is a rare type of oropharyngeal infection that is characterized by thrombosis of the internal jugular vein and multiple septic metastases/emboli.2 Patients with Lemierre syndrome often present with manifestations related to the primary infection such as fever, abdominal pain, nausea, vomiting, or cervical lymphadenopathy. The primary infection progresses to affect the parapharyngeal space invading the posterior compartment along the path of the carotid artery and ultimately leads to a thrombophlebitis of the internal jugular vein.2
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