The following case study was used by James P. Keating, MD, MSc, medical director, St. Louis Children’s Hospital Diagnostic Center, and his co-editor, Andrew J. White, MD, division director of pediatric rheumatology/immunology, as part of the “Patient of the Week” (POW) series. Many of the POW case studies cover uncommon illnesses, or common illnesses with unusual symptoms that can be overlooked. If you would like to be added to the POW e-mail distribution list, send an e-mail message to jkeating@wustl.edu or white_a@wustl.edu.
Ped: Karen Norton
PL3: Melissa Belanger
EM1: Neda Tahmasebi
ID: Indi Trehan/Audrey Odom/Sam Davila
A previously healthy 8-year-old was admitted (7/09) to St. Louis Children’s Hospital with CC: persistent lymphadenitis and swelling behind his ear.
HPI:
7/3: He was on vacation in the Ozarks, staying in a cabin and swimming in a river. No bug bites or tick attachments were recognized. He noticed a bump behind his right ear, a diffuse sandpaper-like rash all over his trunk, fever and intermittent vomiting.
7/5: At an urgent care center, rapid strep test was positive. His rash was gone. Amoxicillin was given. His fevers and swelling behind his ear continued through 7/7 (and beyond).
7/9: His pediatrician started him on cefdinir.
7/9: SLCH ED clindamycin therapy. Slightly better the next two days.
7/12: Fever was higher, and more malaise and retroaural swelling persisted. WBC 10.8, hemoglobin 12.6 platelets 370,000. Neck CT: multiple enlarged right posterior cervical triangle lymph nodes, some with necrosis. No retropharyngeal abscess. Ipsilateral parotid enlargement.
7/15: Swab obtained, which grew out causative agent 7/20.
Course:
IV clindamycin for three days, then IV vancomycin.
CMV and EBV negative
Bartonella serology negative
PPD negative
Aspirate of soft tissue behind ear was negative on gram and acid-fast stain and culture was sterile.
Despite the IV clindamycin and vancomycin therapy, he continued to be febrile
and had no improvement of the swelling behind his ear.
Review of Systems: He had no ocular symptoms or conjunctivitis and no hearing difficulties. He does not have pain in his ear, although he does have pain when his right pinna is touched and pain behind his right ear at the site of the swelling. No URI symptoms. He has no oral lesions. He has no difficulty turning his neck to either direction and he has no meningeal signs. No vomiting or diarrhea, abdominal pain. All other systems reviewed and were negative, except as per HPI.
Family has pet dogs; no cat or kitten contacts. He denies contacts with other any animals, dead or alive, unpasteurized dairy products, or known or suspected TB contacts.
PE: Awake, alert and in no distress. He has a pleasant affect. T-max 38.8 degrees, HR 70s to 80s, RR 20. BP 102/62.
His left ear is normal. Behind his right ear is a 1 cm swelling with a small amount of subcutaneous fluctuance just underneath the skin, with what appears to be a small head forming. This swelling spreads to below his ear and onto his cheek, near his parotid gland. The right pinna is crusted with discharge. No meningeal signs.
Cardiac and respiratory exams are normal. His abdomen is soft, nontender and nondistended. He has no rash. His extremities show no clubbing, cyanosis or edema, and he is neurologically grossly intact.
Problem:
1. Soft tissue inflammation around R ear; persistent fever despite antibiotics.
Impression (ID note): The most likely etiologic agent is (1) group A Streptococcus. Given the community epidemic we are experiencing, we cannot ignore the possibility of (2) Staphylococcus aureus, including
(3) MRSA. The possibility of
(4) Possible viral parotitis.
(5) He has no exposure history to strongly suggest a mycobacterial,
(6) fungal or
(7) Bartonella infection.
(8) Chronic granulomatous disease (CGD) is another possibility, we recommend checking a neutrophil oxidative burst test. CGD has been frequently described as presenting with an isolated lymph node or chain of nodes that, when cultured, grows an unusual organism such as
(9) serratia.
Course: His fever persisted until he was given meropenem. Once he defervesced, he was sent home on TMP/SMX and ciprofloxacin. He has continued to be asymptomatic and afebrile. The pinna was swabbed and grew out francisella tularensis. The serologic test for tularema was 1:80, which is not usually considered diagnostic.
Diagnosis:
1. Tularemia, ulceroglandular type.
Comment: Since he had not been skinning a rabbit, we think he had had a tick behind his ear without knowing it. Incubation time is usually 3-5 days (range 1-21). There are 34-142 cases in the U.S. per annum, many of them in Missouri. If you are outdoors, please wear long sleeves and pants and take a tick removal tool with you ($3.50 at REI on Brentwood). Get your hiking partner to look you over after the hike.
The recommended treatment for tularemia is streptomycin, gentamicin or amikacin. Alternative medications for less severe disease are ciprofloxacin, imipenem-cilastatin and doxycycline. He was afebrile at the time the culture became positive and the course of ciprofloxacin was completed.