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Morning Report

12-28-12
D Spencer Mangum MD, PGY2

Presentation
19 month old presented to the ED with 7 days of

fever and neck swelling.


Day 1-3 of illness: Fever Significant fussiness

Day 4-5 of illness: Fevers increasing (Tmax 40) Continued fussiness Swelling over right neck with warmth / tenderness

Presentation
Day 5 of illness:
PCP diagnosed strep throat based on pharyngeal

erythema (no swab obtained) Amoxicillin started


Day 7 of illness:
Mother brought baby to ER for continuing fevers

with no improvement of neck swelling


On ROS:
No cough, rhinnorhea, rash, or constitutional

symptoms No sick contacts, recent travel, or animal exposure

Presentation
PMHx:
Full term previously healthy male No prior hospitalizations / surgeries No regular medications Immunizations: UTD

NKDA

FHx: No significant childhood or congenital illness SHx: Lives with mother / father, only child

Presentation: Exam
VS: T 39.5, HR 123, RR 28, BP 115/86 (crying), O2

Sat 100%RA GEN: Fussy, not easily consoled HEENT: TMs clear, No conjunctivitis, no cracked lips, MMM, mild pharyngeal erythema, 2+ tonsils w/out exudate, no deviation of uvula / masses, no drooling. NECK: 3x4 area of swelling over the right angle of the mandible extending to the ear, +erythema, +warmth, +tenderness. Hard but no fluctuance. RESP: No increased WOB. CTAB. No stridor / highpitched voice. CV: RRR, +S1/S2, no murmur appreciated ABD: Soft, NT/ND, +BS, no hepatosplenomegally EXT: WWPx4, No edema. SKIN: No rash.

Differential Diagnosis?

Diff. Dx: Unilateral cervical Lymphadenopathy


ID:
Bacterial Lymphadenitis

Rheum:
Kawasaki

Cellulitis (Ludwigs Angina) Retropharyngeal abscess Lemierres Syndrome

Sarcoidosis Lupus

(Complication of pharyngitis Lymphoma leading to thrombophlebitis of the Lymphoproliferative disorders jugular vein Caused by Soft tissue Neoplasm fusobacterium) Cat scratch disease (Bartonella Congenital: Henselae) Thyroglossal duct cyst (midline) TB / Scrofula (Mycobacterium Branchial cleft cyst (anterior scrofulaceum or Mycobacterium along SCM) avium) Cystic hygroma (posterior above clavicles)

Oncology:

Labs / Imaging:
CBC: WBC 17 (33% Bands, 33% Neutrophils,

26% Lymphocytes), Hgb 12, Plt 240 ESR: 69 CRP: 4.4 Head CT: Asymetric soft tissue swelling with enlargement of the right cervical anterior lymph nodes. No abscess appreciated.

Hospital Course
Diagnosed with cervical bacterial lymphadenitis Given a dose of Clindamycin -> an erythematous rash to

the face and trunk was noted and changed to Unasyn Next AM, noticed improved swelling but continued fevers Reassessment:
Dry cracked lips with red tongue and swollen red palms

CRP: 4.4 -> 8 Hgb: 12 -> 10.8 Plt: 240 -> 356
U/A: 10 WBCs with no bacteria, nitrite / leuk esterase AST / ALT: 101 / 100 Albumin 3.3 Kawasaki Disease with isolated lymphadopathy (KDiL) confirmed Patient improved after IVIG x2 and high dose aspirin

Kawasaki Disease
Fever x5 days with 4 of 5 following:

Polymorphous rash Conjunctivitis (non exudative, limbic sparing) Cracked lips / strawberry tongue Cervical lymphadenopathy > 1.5 cm Changes to the palms / soles (red, edema, desquamation)

Unofficial criteria: Fussiness. Not all criteria need to be present at same time (get good

history) Treat with IVIG / High dose aspirin to avoid complications (Coronary artery aneurysm) If not enough clinical criteria met, Incomplete Kawasaki can be met with labs:
ESR>40, CRP>3, WBC>15, Anemia for age, Plt >450, Sterile

pyuria (>10 WBCs), Alb<3, Elevated ALT If ESR / CRP elevated -> get Echo regardless, and treat if 3+ other labs consistent or Echo consistent with KD

KDiL
Initial presentation of only fever / cervical

lymphadenopathy Often diagnosed with bacterial lymphadenitis


Diagnosis of KDiL often delayed or not at all

May represent more severe form of KD:


Older at presentation More coronary aneurysms (25% vs 5% when

treated) More non-responders to 1st IVIG dose (38% vs 10%)


TAKE HOME POINT: Always keep Kawasaki in

back of mind if diagnosing / treating cervical bacterial lymphadenitis

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