Case Study: Trouble Chewing in 4 Year Old
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, Andrews 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 to jkeating@wustl.edu or white_a@wustl.edu.
PL3: Angela Scott/Amanda Carrion
PNP: Elise G’sell
ID: Mike Watson/Celeste Morley
Hosp Epidemiologist: Alexis Elward
International Adoption Clinic: Rachel Orscheln
ED: Charles Eldridge/Jared Muenzer
Au: Katherine McMullin Jones
This 4 year old came with a CC: trouble chewing.
HPI: Until two weeks before admittance to SLCH, he was in an Ethiopian orphanage. A family in Texas, who recently moved to a St. Louis suburb, adopted him. Mother saw that he was having discomfort chewing the day of admittance. He has no English. She thought the left side of his face was swollen and she felt several knots in the L supraclavicular area.
PMH: Said to be healthy. Immunization status unknown.
PE: T 37.7Wt 17.4 (25%) Palpable nodes in left neck all subcentimeter, slightly tender, mobile. Face probably full on L but no palpable mass or tenderness. L submandidular tender mass 1.5 cm in diameter. By mother’s account, rapidly enlarging preauricular swelling. No meningeal signs.
Differential (in ED very thoughtful but did not include the correct diagnosis): Scrofula (tuberculosis cervical adenitis), EBV, HIV, atypical mycobacteria, odontogenic, Burkitt’s, Hodgkin’s, bartonella, sarcoid, pneumoparotitis (self-induced). Although not mentioned initially, the serologic test was sent and returned after discharge.
Lab: WBC 6.6 Hgb 12 N 50 L36 Mono 11 ESR 11 IgG 1087 LDH 347 BUN 20 Alb 4.3 Hep B negHep A neg RPR neg tetanus toxoid 4.27 (successful immunization)CMV G pos. M neg. Toxo G neg. M neg. EBV M neg. Rubeola G pos.
Imaging: Bilateral supraclavicular nodes.
Working diagnosis: Parotitis and submandibular gland swelling.
After discharge, the mumps IgM was 4.02 (0.0-0.75) IgG 2.5 (0.0-0.89), and both the stool antigen test (at SLCH ordered as “O+P screen") and the microscopic examination were positive for giardia lablia.
Final:
1. Mumps
2. Giardia, asymptomatic
Rx:
1. Metronidazole 15 mgm/d in three divided doses for 5 days (Harriet 15th Ed.)
2. Recommended immunization schedule for children <7 years old not immunized in the first year of life (Harriet 15th Ed. p 347).
Comment: This is a typical story of mumps. The patient is not very ill and the presence of parotitis is a subtle visual (rather than palpable) finding most appreciated by the mother, who knows the child’s healthy appearance. The submandibular salivary glands are sometimes more prominent than the parotid.Fifty percent of patients with mumps have a mononuclear pleocytosis (most without neurological signs or symptoms)and, sometimes confusingly, they have hypoglycorrhachia, leading to unnecessary antibiotic therapy.
Mumpsis very contagious, even in a hospital following universal precautions, so patients with mumpsare best kept at home. Recent outbreaks in this country have demonstrated that immunized adults whose immunity has waned are important in the spread of the infection. A Syracuse, NY, physician, after foreign travel, worked in an NICU, which lead to four additional cases in health care workers (HCW). By testing, 10 percent of immunized HCW were susceptible.
Rare complications of mumps: arthritis, thyroiditis, mastitis, myocarditis, endocardial fibroelastosis, thrombocytopenia, cerebellar ataxia, transverse myelitis, ascending polyradiculitis, oophoritis, hearing impairment, orchids.
Treatment of asymptomatic giardia as he is moving from an environment where re-infection would be inevitable to an environment where the likelihood of re-infection is very low is a reasonable effort to reduce the likelihood of spreading that infection.
