Case 2: Scalp Lesion and Neck Swelling in a Female Adolescent

Abstract

1. Karin Lammert, MD* 2. Adam Dell, MD* 3. Merium Saidi, MD* 1. *Department of Pediatrics, University of Utah, Primary Children’s Hospital, Salt Lake City, UT A previously healthy 15-year-old female adolescent is admitted to the hospital with fever, neck swelling, and failure to improve while taking multiple antibiotic agents. One month ago she noticed a lump behind her left ear; it resolved spontaneously but recurred approximately 3 weeks later along with tenderness and fevers. Around this time she had a raised, scabbed lesion on her left scalp, which her sister lanced. Her pediatrician started the patient on amoxicillin/clavulanic acid. Five days later she presented to the emergency department with persistent fevers. A complete blood cell count was normal and a neck computed tomographic (CT) scan showed diffuse subcutaneous edema consistent with cellulitis, so she was started on cephalexin and trimethoprim/sulfamethoxazole and was discharged. However, her symptoms worsened, with continued fevers, vomiting, pharyngitis, and swelling of the area behind her left ear. She returned to the emergency department 3 days later and was admitted to the hospital for failure to improve with outpatient antibiotic drug therapy. The patient is otherwise healthy and up to date on immunizations. She lives with her parents and a younger sister on a farm in central Utah, with exposure to multiple farm animals. She reports that she has been camping recently and denies any insect bites. She has never been sexually active. She has tried marijuana but denies other illicit drug use. Physical examination reveals a tired-appearing teenager in no acute distress. The left parietal scalp has a 1×2-cm ulcer with flat-topped papules and overlying hemorrhagic crusts (Fig). There is diffuse swelling extending from the left mastoid process anteriorly to the angle of the mandible that is tender but without …