Visual Diagnosis: Swelling of the Left Side of the Neck in an Adolescent

Abstract

1. Raghu Varier, DO* 2. Laura Plencner, MD* 3. Douglas Rivard, DO† 4. Angela L. Myers, MD, MPH* 1. *Department of Pediatrics, Children's Mercy Hospitals & Clinics and The University of Missouri-Kansas City, Kansas City, MO. 2. †Department of Radiology, Children's Mercy Hospitals & Clinics and The University of Missouri-Kansas City, Kansas City, MO. A previously healthy 13-year-old girl presents to the emergency department with a 2-week history of worsening sore throat and a 4-day history of left neck swelling, pain, and fever. Results of evaluation by a prior clinician at the onset of symptoms included a negative rapid streptococcal antigen test and a positive heterophile antibody test, prompting treatment with oral corticosteroids for 5 days as an anti-inflammatory medication. The girl now reports pain with swallowing, decreased oral intake, and left-sided head tilt for the past 24 hours. On physical examination, the girl has a temperature of 38.4°C and appears to be in no acute distress. In addition, her heart rate is 91 beats/min, respiratory rate is 20 breaths/min, and blood pressure is 119/69 mm Hg. She has a warm, very tender, firm, anterior, left-sided 1.5-cm mass at the level of the thyroid gland. The mass moves when she swallows. Findings on the rest of her physical examination are normal. Laboratory investigation reveals a white blood cell count of 17.2×103/μL (17.2×109/L) with 74% neutrophils and 14% lymphocytes, hemoglobin of 13 g/dL (130 g/L), and platelet count of 423×103/μL (423×109/L). C-reactive protein (CRP) measurement is elevated at 1.6 mg/dL (normal, 0.3 to 1.0 mg/dL). Computed tomography (CT) scan of her neck with intravenous contrast enhancement suggests the diagnosis (Fig. 1). Figure 1. Axial computed tomography scan of the neck with intravenous contrast enhancement. The patient's physical and laboratory findings and CT scan of the neck are consistent with acute suppurative thyroiditis. The CT scan reveals a multilocular inflammatory phlegmon/abscess-in-evolution involving the superior pole of the …