Red in the Face: Make the Diagnosis

Abstract

A male presented to the emergency room with bilateral facial swelling and erythema. He had no past medical history; he was taking no regular medications and had no known allergies. He had been perfectly well until seven days earlier, when he noted the onset of fever and myalgias, with no other symptoms. He took occasional acetylsalicylic acid in an attempt to control the fever and aches, but his fever persisted and ranged from 37.2°C to 37.8°C. He denied any chills, sweats, headache, tooth pain, chest pain, shortness of breath, urinary symptoms, diarrhea, joint pains or rash. He did feel tired, but continued to work. One day before his presentation, he noted the onset of diffuse redness over his entire nose, with progression to bilateral facial redness and swelling after 24 h. There was no history of recent travel, insect bites or facial trauma. On examination, the man appeared nontoxic and comfortable. Oral temperature was 38.8°C, and other vital signs were normal. Impressive bilateral facial swelling and erythema were apparent (Figure 1), including bilateral periorbital involvement. The head and neck examination was otherwise normal, with no evidence of pharyngitis or sinus tenderness. Examination of the ears was normal. There was no adenopathy, and the rest of the examination was normal. Routine blood tests showed a normal hemoglobin of 145 g/L and platelet count of 219×109/L, with an elevated leukocyte count of 18.1×109/L. Two sets of blood cultures were drawn. What is the cause of this man’s painless facial swelling, erythema and fever? What diagnostic test would you perform? CLINICAL VIGNETTE