This is a 10 year old African American female with history of eczema, presenting with a 6 day history of right-sided posterior neck erythema and swelling that has been progressively worsening.
She initially noticed a ‘painful bump’ over her posterior neck and was seen by her primary care physician that same day and was started on twice daily oral amoxicillin-clavulanic acid which she has been taking without missed doses.
She reports some improvement in her symptoms for 3 days but then developed increase pain and swelling. She was seen by her primary today and was sent over to you at UMC.
Review of symptoms
Constitutional – No fevers, malaise or lethargy
Skin – As above
HEENT – No sore throat, nasal congestion, conjunctivitis
Respiratory – No cough
Gastrointestinal – No vomiting or diarrhea
Patient has not had any recent travel abroad. She is fully vaccinated. She denies history of insect bites.
Examination
VS: Normal temp, HR, RR, and BP
Gen – Alert, well perfused, in no distress
HEENT Normal pharynx, normal TMs, no pain or erythema over mastoid process. Right posterior neck swelling (3cm x 3cm) overlying trapezius, warm, erythematous, tender to palpation, non-fluctuant. Neck range of motion limited by pain, no neck stiffness, Anterior neck – no swelling.
Lymph nodes – no lymphadenopathy
CVS – No murmurs, rubs or thrills, neck bruits or JVD
Chest – Clear to auscultation bilaterally
Abdomen- Soft, non-distended, no organomegaly
Neuro – Cranial nerves intact – although some pain on evaluating spinal accessory nerve on R side when asking patient to shrug her shoulders and turn her head against resistance to the left
The patient’s family is eager to leave and report good PMD availability.
Questions for you (hit "Vote" to submit your answer and see what others said):
Come back later for the Hot Seat response by Jim and case denouement.
3x3cm isn't all that impressive. it sounds like an infected brachial cleft cyst. the fact that it's red and painful is reassuring to me, because it means infection. it's more tricky for non-painful neck masses because you have to think about things like scrofula, mycoplasma, lymphoma, rhabdo/soft-tissue tumor, etc. Augmentin is ok, but probably doesn't cover MRSA, so i would probably just change this kid to clindamycin and have f/u with PCP. US is ok, but only if you are going to intervene with the results. so if there is a small deeper abscess in the neck in an afebrile child, is it worth an ENT-guided drainage in the OR when maybe a few days of clinda would take care of the job? Doesn't sound like an ill-appearing child where i should be considering lemieres disease (need for blood cx and more aggressive tx). I'd probably assume this is lymphadenitis vs. infected cyst and treat with oral meds, but if patient doesn't respond or develops high fevers, i'd take the next steps. but i'm a minimalist and only like to tests if they change my management :)
ReplyDeleteDDx is mostly in the infectious category.
ReplyDelete- Top culprit: Staph aureus. From where? In that location, I think less of the oropharynx and more of the scalp/chest or arms.
Scalp: African American girls who braid their hair can get traction alopecia --> inflammatory hair folliculitis --> local LAD --> can progress to local lymphadenitis). Would do a good scalp exam - drain any pustules or bacitracin any folliculitis; and would recommend de-braiding to relieve tension/inflammation.
Arms/chest: re-ask cat/puppy hx for cat-scratch. re-ask TB contacts and systemic sx of TB. Place PPD to be checked at PMD office. (side note - Augmentin was a 3rd line agent we occasionally used in Botswana as part of a larger anti-TB regimen and often kids with TB-Lymphadenopathy had "some" improvement, like this girl, with Augmentin that was had been used by OSH to treat "simple presumed Staph lymphadenitis"). Full chest exam as well to check for staph infections.
Other considerations much less like on Ddx would be oncologic (unlikely given no systemic sx, localized, red/warm ; mobility of mass not commented upon...?), sarcoid (no other regional LAD, no other systemic sx), traumatic (no hx of traums, but an acute muscle spasm following a hematoma could get infected from low blood flow...). Would probably not go down any further imaging workup at this time until staph treated effectively with (bactrim or clinda) + hygiene/hot compresses.
I don't have much to add to what Dave and Paul stated above. The only thing I'd like to clarify is that branchial cleft cyst/abscesses present in the anterior cervical triangle (classically along the anterior border of the sternocleidomastoid muscle), not in the posterior neck along the trapezius muscle as described here.
ReplyDeleteInfections such as tinea capitis, mono, bartonella can cause post adenopathy. This sounds as if the lymph node is itself infected, with staph/strep as suggested above, as opposed to being reactive. My first thought was to say that this child has failed outpatient therapy, since Augmentin is a good antibiotic for lymphadenitis. But there hasn't been a sufficient trial with meds directed at MRSA, so Bactrim (also effective against Bartonella if that is strongly in differential) or Clindamycin with f/u in 48hrs would be a better choice. Provide instructions to return for: rapid growth of mass, neck stiffness, pain with swallowing.
ReplyDeleteDewesh is right here, but remember that there are three types of branchial cleft cysts. i learned from this blog that it's branchial and not brachial :) they're all usually along the line of the sternocleidomastoid....hence the pain with lateral rotation of neck. 2nd branchial cysts are more posterior. http://pediatric-ent.com/wp-content/uploads/LUMPNECK-2nd_ba.gif
ReplyDeletehere's a good image of all three locations:
http://gzy.hainmc.edu.cn/jingpin/renjie/jiaoxueziyuan/tesemokuai/chuangxinleyuan/yingwenbingli/jbywblfx_clip_image002_0001.jpg
Whenever I’m asked to evaluate a mass or swelling, I try to get at three important questions. First, what lives in that area? Second, is there something herniated and incarcerated that I need to do something about immediately to prevent morbidity? Third, does this seem infectious (i.e. something I can treat in the ED)? While I always keep malignancies, atypical Mycobacteria (especially in this region), TB, and cat scratch disease in my differential, these are less common than simple reactive lymphadenopathy and soft tissue bacterial infections. I would certainly probe the family for travel history, history of someone with possible TB in the family, and the presence of a cat who likes to scratch.
ReplyDeleteRegarding the first question, the anatomy of the posterior neck is straightforward. There is skin, muscle, some lymph nodes, and then the deeper vessels and bones of the spine. One important thing to note is that the lymph nodes under the trapezius muscle may drain down from the head or up from the thorax, depending on how caudad you are. The mass described in this patient sounds superficial as the description is “overlying trapezius.” I will take the examiner’s word for it and dismiss problems with the deeper structures, including the lymph nodes. Similarly (without the benefit of my own exam), I will interpret the stated exam as exhibiting very little muscle spasm, so an injury or infection of the muscle itself is also unlikely.
While a trapezius muscle hernia could conceivably be present, I have never seen one (this is an unusual location). Directly beneath the trapezius are two additional muscle layers, so herniation here would be unusual and would not cause significant morbidity.
The warmth and redness suggest an infectious process. The patient’s underlying eczema predispose her to bacterial skin infections.
I would perform a sono of the mass to determine whether there is pus to drain. Assuming there is no pus, I would change antibiotics to clindamycin, which should be more effective than Augmentin at treating MRSA. I could not find a lot of data on this, but in one study in India, 87% of MRSA were resistant to Augmentin. (Vidhani S et al, Ind J Med Microbiol 2001). I would encourage the family to apply heat to the area to increase blood flow and increase bactericidal activity of white blood cells. Finally, Staph infections can follow an indolent course, then blossom into an overwhelming infection. Therefore, close follow-up with the PCP is required, and a phone call to the PCP should seal this.