A Diagnostic Dilemma: Sometimes You’ll Never Know

Patient Presentation
A 9-year-old male came to clinic with a 1 month history of painful joint swelling. One month ago he started having right ankle pain that was intermittent but consistent. One day ago his right wrist, right ankle and bilateral knees had some swelling but no erythema or warmth. He says that he has pain in them when he moves but not when he is resting and he denies any joint stiffness or gelling. He also had 1-2 days of multiple red skin lesions on his extremities and trunk, not overlying the affected joints. The skin lesions do not come and go and do not itch. They are mainly discrete circular lesions with no central clearing and did not change since they noticed them. The father and patient deny any recent infections but his sibling had a strep throat a few weeks ago. They had used ibuprofen and diphenhydramine orally once each without any symptom changes. They denied any contact with animals, ticks bites or non-city water supply. They deny any travel or contact with others from oversees, military personnel or institutionalized persons. They denied any history of trauma, no medication or other drug use and the child was not under unusual stress.

In the review of systems he denies any fever, chills, no eye changes, muscle aches, no pain in general and sore throat or ear pain specifically, and weight changes or clothing fitting differently. He has no problems with breathing or swallowing, problems on exertion, heart palpitations, syncope or any gastrointestinal or genitourinary complaints including colors in stool or urine color. He denied any bleeding but had some bruising of his shins from playing. He has been sleeping, eating and acting normally. The past medical history is positive for mild intermittent asthma but no allergies. The family history is positive for a maternal grandmother with arthritis and psoriasis.

The pertinent physical exam overall looked well. He had a heart rate of 88 beats/minutes, respiratory rate of 20 breaths/minute, blood pressure of 96/62, and temperature of 37.2°C. His weight was 75% and height was 50% and were tracking. He did not have generalized edema. HEENT specifically showed no facial swelling, eye or pharynx changes. Heart examination showed a new musical systolic II/VI murmur best at the mid left sternal border. Lungs and abdomen were normal. Genitorurinary examination showed no mucosal changes of the urethra or anus. He had some shotty anterior cervical and inguinal adenopathy. There were no posterior, occipital, axillary, elbow, or knee adenopathy. Tonsils were 2+ and his spleen and liver were normal sized. His musculoskeletal examination showed his right wrist, right ankle and bilateral knees had some swelling with the right ankle and bilateral knees being more prominent and slightly warmer. There was no overlying erythema but the right ankle and bilateral knees had some warmth. He complained of pain with movement of these joints, but was not able to say if it felt to be the joint itself or the swelling around it. He denied any pain in actual muscles upon palpation. He had no pain in small joints including the hands, feet and temporomandicular joint. His skin examination revealed 1-3 mm erythematous plaque-like lesions with a uniform but slightly serpigenous border that were slightly-raised across the entire lesion, reddened without scale and had no specific central-clearing. They were not painful nor pruritic and these could not be elicited with palpation or stroking. He also had 2-3 similar lesions on his shins that were more nodular in the center with slight darkening of skin laterally.

The diagnosis at this time included possibly rheumatic fever (possible new heart murmur, possible erythema marginatum, joint swelling and subcutaneous nodules), Lyme disease (rash and joint swelling), erythema multiforme (rash but without target lesions), atypical urticaria (swelling of areas of the body but without pruritis), arthritis (juvenile idiopathic arthritis or psoriatic), other autoimmune disease, and viral syndrome including it causing idiopathic localized edema. There were no obvious signs of acute infectious problems, no history of trauma, no drugs and specific stressful social situations so problems related to those were not considered as likely. Atypical Kawasaki Disease was contemplated but the patient had no history of fever or mucositis. Occult malignancy was considered. The resident was unclear as to how to proceed and the supervising attending also had another faculty member look at the physical findings who also agreed with that general differential diagnosis.

Because of the concern for rheumatic fever and the patient had a laboratory evaluation that included a complete blood count that was normal except slightly large platelets. Urinalysis and culture, rapid streptocococcal testing, complete metabolic panel, erythrocyte sedimentation rate and creatinine kinase were normal. C-reactive protein was 0.8 mg/dl (normal < .05 mg/dl) The electrocardiogram was negative.

The patient clinically was started on diphenhydramine and ibuprofen around the clock with clinic for possible urticaria or rheumatological disease with followup in 2 days. Telephone contact the next day revealed that the patient was about the same to slightly better. The family did not show up for clinic the next day, but notes from an emergency room visit the previous evening showed that they had been worried that the swelling had gone away in the wrists and most of the knees, and now his left foot was swollen. The emergency room also wasn’t sure what this was but thought that some of the skin lesions had migrated and may look more “hive-like.”

Laboratory testing now returned showing a normal anti-streptolysin O but abnormal anti-DNase B antibodies of 1350 (normal 0-310 U/ml). An infectious disease consultant said these levels could last for a long time and felt that with the other testing and history this was not rheumatic fever but recommended a Lyme titre be completed. A rheumatology consultant felt that at this time a vasculitis could be the cause and recommended to monitor the patient while continuing the ibuprofen, do an ultrasound of the joints to see where the actual swelling was if the patient came in, and schedule an appointment with rheumatology in the next few days. Serum ferritan and Lyme titres were eventually negative. On the telephone later that day the parents reported that the swellings and skin lesions were resolving. The joint pain had gone away and maybe one or two of the skin lesions were now slightly pruritic. They also now remembered that he had a significant fall on the playground 1 month ago and had been complaining of the right ankle pain before the current episode. He returned for his health maintenance examination 5 days later and all symptoms had resolved so no further evaluation was completed. It was thought this was most likely a hive reaction to an unrecognized virus.

Discussion
It can be difficult to consider what is the problem when a health care provider is presented with a group of seemingly disparate signs and symptoms with a history and time course that do not match classic (or commonly atypical) disease presentations. Common things happen commonly, so when symptoms occur without the usual co-occurring symptoms, unusual symptoms or time courses, it can be challenging. The provider must develop a reasonable differential diagnosis and balance how far to go with the evaluation against how much to monitor the patient for new signs or symptoms which can provide new information. Patient safety and the natural time course of diseases have to be considered. Providers also recognize that well-appearing individuals with acute onset of problems usually have a common problem such as a viral syndrome and have to balance that knowledge. The judicial use of laboratory testing and other health care providers’ expertise to help clarify some of the confounding problems, and give guidance and reassurance for the provider as he/she works through a diagnostic dilemma.

The provider was presented with chronic joint pain with acute swelling. While this could be a virus, occult trauma, malignancy, rheumatological disease or even an unusual infection such as tuberculosis are potential considerations.
A differential diagnosis of leg pain can be found here. Early symptoms of rheumatological disease can overlap with many common illnesses. A review of juvenile rheumatoid arthritis can be found here

The provider was also presented with a rash that had characteristics of several different rash types. These characteristics are less likely to be an acute infectious rash but idiopathic urticaria or a vasculitis are potential possibilities.
A differential diagnosis of rash can be found here

With potential subcutaneous nodules, especially on the shins, trauma is very common, but rheumatic fever and erythema nodosum are also considerations.
Causes of erythema nodsum can be reviewed here

Allergic symptoms are known to cause common or unusual swelling of various body parts but normally pruritis accompanies the lesions and the lesions usually will change shape more quickly.
A differential diagnosis of acute urticaria can be found here

Often patients have functional murmurs that may not be documented or they are documented during a hypercatabolic state such as when a patient is febrile. However with a new murmur other diseases must be considered such as rheumatic heart disease or other valve issues, cardiomyopathy, or arrhythmia.
A differential diagnosis of heart failure can be found here – along with sudden death here

Occult malignancy is a diagnosis no clinician want to consider but like many of the problems listed above, early signs can overlap with many other diseases.
A review of leukemia can be found here

Learning Point
In evaluating a diagnostic dilemma, starting the laboratory evaluation helps to begin the process of trying to find an answer and can also help the families as “something is being done.” Watchful waiting is appropriate in many circumstances but can be difficult for the health care provider as well as the families. First symptoms are sometimes just that, first symptoms. It takes time for other features of a disease process to become manifest.

Families will often be quite concerned and support for them is also necessary and close communication and followup is appropriate. Families are trying to give good information but sometimes it is not available them. Sometimes new information becomes available after parents talk with other family members (common for family history) or other people such as teachers or child care professionals may also have additional history to offer. Use symptom diaries gathers important data and engages the family in “doing something.” The symptom diaries can be very important tools in understanding and sorting out the timing, duration, severity, aggravating and elevating factors of the patient’s symptoms.

Health care providers themselves can be concerned that they are “missing something” or possibly overlooking something else in the differential diagnosis (rare diseases or new diseases do occur). Careful attention to the timing of history, physical examination and laboratory findings is always important. With diagnostic dilemmas, it may just “take more time” and clinicians and families have to be patient, or the symptoms may go away, and everyone may “never know what happened.” Sometimes patients have to be admitted to hospital for closer monitoring and evaluation.

Questions for Further Discussion
1. What are indications for admitting to the hospital for further evaluation?
2. What types of common problems are diagnostic dilemmas?

Related Cases

    Disease: Diagnostic Dilemma | Hives

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Hives

Information prescriptions for patients can be found at MedlinePlus for these topics: Topics and Topics.

and at Pediatric Common Questions, Quick Answers for this topic: Topic

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Khanna K, Liu DR. Acute Rheumatic Fever: An Evidence-Based Approach To Diagnosis And Initial Management. Pediatr Emerg Med Pract. 2016 Aug;13(8):1-23.

Pattanaik D, Lieberman JA. Pediatric Angioedema. Curr Allergy Asthma Rep. 2017 Aug 8;17(9):60.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Spring Break

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We appreciate your patronage,
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What are Indications for Allergen-specific Immunotherapy?

Patient Presentation
A 14-year-old female came to clinic with increasing seasonal allergic rhinitis symptoms during the fall. She had increased her cetirizine to 60 mg day and nasal fluticasone to 2 puffs twice a day but still had significant symptoms. Her parents reported that she had snoring without apnea, was always mouth-breathing and had a de-nasal voice. Her running coaches had talked with her twice over the running season as they noticed that she was noticeably pale, and had more problems breathing over the course of her daily workouts. The main reason she came in was that she felt she could not breath at the end of her cross country races because she was “full of snot” and couldn’t catch her breath. “Maybe I can really run if I can breath,” she commented. The past medical history showed mild intermittent asthma with albuterol use averaging 1x/year, seasonal allergic rhinitis usually from March to November that had been resistant to fexofenadine and montelukast in the past. She also had some mild xerosis that had never needed steroid creams. She also had a history of moderate nasal stuffiness when in contact with cats. The family history was positive for mild seasonal allergic rhinitis in some family members. The review of systems was otherwise negative.

The pertinent physical exam showed a healthy female with normal vital signs and weight that was 25% and height that was 50%. She had allergic shiners and cobblestoning of her palpebral conjunctiva. Her nose showed significant edema and a bluish color. With pinching one nare at a time, where was no air movement in either nare. She also had cobblestoning of her posterior pharynx. Her lungs were clear. She had mild dry skin. The rest of her examination was negative.

The diagnosis of persistent seasonal allergic rhinitis that was not effectively treated by medications was made. She was referred to an allergist and skin testing found her to be allergic to several grass pollens, Alternaria alternata mold and cat dander. She was restarted on fexofenadine and montelukast daily and began allergen-specific immunotherapy. At her next appointment she was feeling better but it was also during the winter when she usually improved.

Discussion
Allergen-specific immunotherapy (AIT) is a disease modifying treatment for allergic disease. Sometimes referred to as desensitization, the premise is to expose the patient to small but regular amounts of a specific antigen thereby building tolerance within the patient to the allergen. AIT is often underused because of safety concerns and lack of appropriately trained health care providers and facilities to safely carry out AIT treatment. There are 4 main AIT treatments options currently:

  • SCIT – subcutaneous immunotherapy
    • Allergen is injected into the subcutaneous skin
    • “Shots are effective in treating reactions to many allergens, including trees, grass, weeds, mold, house dust, dander, and insect stings.”
    • SCIT is safe when used for selected individuals and given by trained health care providers in a setting that has immediate access to treatment for anaphylaxis and resuscitation.
    • Reactions are infrequent and usually localized with erythema or hives. Rarely anaphylaxis can occur.
    • Patients with concomitant asthma have an increased risk of severe bronchospasm. Patients should also not exercise for 2 hours before or after injection.
  • SLIT – sublingual immunotherapy
    • Allergen drops or tablets are placed and held under the tongue for several minutes and then swallowed. Used for food allergies such as peanut allergy.
    • Ragweed and pollen tablets and drops used in other countries. In the US tablets for grass, ragweed and house dust mite are available.
    • Reactions are more common at the beginning of treatment with problems such as oropharyngeal pruritis and angioedema occurring
  • OIT – oral immunotherapy
    • Allergen in tablet/capsule or other measured allergy (i.e. peanut powder) is swallowed. Commonly OIT is used for milk, eggs and peanuts allergy.
  • EPIT – epicutaneous immunotherapy
    • Allergen patches are placed on the upper body and changed daily. Used for peanut allergy and has modest effects while being used but not of sustained benefit

In general, single antigens are more effective than mixtures of antigens for SCIT but may be necessary. Both SCIT and SLIT have been found to have benefit for some years after stopping therapy. Both SCIT and SLIT are safe to use. SLIT appears to have a better safety profile but there are no head to head comparisons of efficacy. “The ultimate goal of AIT safety is to completely prevent fatal reactions, but one must consider that with such treatment amounts of the causative allergen much larger than those associated to natural exposure and administered, the potential risk is unlikely to be completely eliminated.”

Food allergies affect ~4% of children and 1% of adults in the U.S. Most common allergens in the U.S. are milk, eggs, peanuts, tree nuts, soy, wheat, fish and shellfish. Milk and eggs are commonly outgrown by school age but peanut allergy is usually life-long. The LEAP study (Learning Early About Peanut Allergy – http://www.leapstudy.co.uk) found a decrease in peanut allergy at 60 months of age with early introduction of peanut foods to infants. A review can be found here along with recommendations for introduction of peanut allergy to infants.

Patients must have confirmed skin or in vitro testing for specific antigens before any type of AIT is initiated.

Patients and families should have reasonable expectations for AIT:

  • Treatment will not be curative and symptoms may only be reduced – typically 30-40% symptom reduction for allergic rhinitis
  • Effectiveness often continues after completed treatment but it depends on the allergen and the patient
  • Families need to commit to treatment that is usually for 3 years or longer, and consider medical cost, transportation, time in the clinic and other arrangements that are necessary such as absences from school, how treatment over vacations will occur etc.
    Economic analyses find AIT to be cost effective but the amounts depend on the type of AIT and the analysis.

  • Symptom improvement may not be seen for several months

Contraindications to AIT include:

  • Absolute
    • Uncontrolled or unstable asthma
    • No initiation in patients receiving beta-blockers as these can make anaphylaxis difficult to treatment
  • Relative
    • Autoimmune disorders
    • Chronic disorders that impair tolerance to bronchospasm or hypotension
    • Immunodeficiency and immunosuppressive agent use
    • Malignancy

Indications for allergy testing and allergy referral can be reviewed here.

Learning Point
Immunotherapy indications include:

  • IgE medicated seasonal pollen induced rhinitis where patients have not responded to optimal pharmacological management especially those with moderate to severe intermittent symptoms or persistent symptoms
  • Systemic reactions to hymenoptera venom
  • Animal danger or house dust mite allergy where patients have not responded to rigorous allergen avoidance and pharmacological management

Questions for Further Discussion
1. What conditions are recommended for SLIT therapy administration?
2. How do these conditions differ from SCIT therapy administration?
3. When should skin testing versus in vivo allergy testing be used?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Allergy and Hayfever.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Frati F, Ridolo E, Fuiano N, et.al. Safety of sublingual immunotherapy in children. Expert Opin Drug Saf. 2014 Jul;13(7):947-53.

Walker SM, Durham SR, Till SJ, et.al.; British Society for Allergy and Clinical Immunology. Immunotherapy for allergic rhinitis. Clin Exp Allergy. 2011 Sep;41(9):1177-200.

Jutel M, Agache I, Bonini S, Burks AW, Calderon M, Canonica W, et.al. International Consensus on Allergen Immunotherapy II: Mechanisms, standardization, and pharmacoeconomics. J Allergy Clin Immunol. 2016 Feb;137(2):358-68.

Meltzer EO. Hot Topics in Primary Care: Sublingual Immunotherapy: A Guide for Primary Care. J Fam Pract. 2017 Apr;66(4 Suppl):S58-S63.

Pajno GB, Bernardini R, Peroni D, et.al.; Allergen-specific Immunotherapy panel of the Italian Society of Pediatric Allergy and Immunology (SIAIP). Clinical practice recommendations for allergen-specific immunotherapy in children: the Italian consensus report. Ital J Pediatr. 2017 Jan 23;43(1):13.

Berings M, Karaaslan C, Altunbulakli C, Gevaert P, Akdis M, Bachert C, Akdis CA. Advances and highlights in allergen immunotherapy: On the way to sustained clinical and immunologic tolerance. J Allergy Clin Immunol. 2017 Nov;140(5):1250-1267.

Jones SM, Burks AW. Food Allergy. N Engl J Med. 2017 Sep 21;377(12):1168-1176.

Allergy Shot Overview. American College of Allergy, Asthma, and Immunology.
Available from the Internet at http://acaai.org/allergies/treatment/allergy-shots-immunotherapy (cited 1/12/18).

Allergy Immunotherapy. American College of Allergy, Asthma, and Immunology.
Available from the Internet at http://acaai.org/allergies/allergy-treatment/allergy-immunotherapy (cited 1/12/18).

Allergy Tablets (Sublingual Immunotherapy). American College of Allergy, Asthma, and Immunology.
Available from the Internet at http://acaai.org/allergies/allergy-treatment/sublingual-immunotherapy-slit/allergy-tablets-sublingual-immunotherapy (cited 1/12/18).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

How Do Deep Neck Infections Present?

Patient Presentation
A 7-year-old female came to clinic with a 2 day history of general fatigue. Initially she had a low grade fever of 100.5°F but this had increased over time to 101.8°F. She also was now drinking less and hadn’t urinated in 6 hours. Her father noted over the day she seemed to be having neck stiffness and was only wanting to hold her head tilted to the right. On her way to the clinic she complained of a minor sore throat. There was strep throat circulating in her school. The past medical history was non-contributory and she was fully immunized. The review of systems showed no rash, emesis/diarrhea, cough, dysphonia, difficulty opening/closing her mouth, or ear or neck pain.

The pertinent physical exam showed a moderately ill-child. Her temperature was 101.7°F, respiratory rate of 22, pulse of 124, and she had a normal blood pressure. She was fatigued and fussy but would cooperate with examination. She had full range of motion in her neck but did have a preference of a right head tilt. Her ears were normal. Her pharynx showed 2-3+ tonsils that were red without exudates or palatal petechiae. There was no asymmetry of the tonsillar pillars or uvula. No bulging was noted in the posterior pharynx. Her lips were slightly tacky. Her teeth showed no pain with tapping. Her neck had no obvious asymmetry and she had some anterior and posterior cervical shotty lymph nodes. Her neck had no palpable tenderness. Her heart, lungs and abdomen were negative. She had no rashes and her capillary refill was 3 seconds

The work-up of a rapid strep test in the office was negative. The child appeared sicker out of proportion to her history and was mild-moderately dehydrated, so the patient was transferred to the emergency room. The attending and resident in the clinic felt that the patient may have a viral syndrome that would improve with fluids, viral meningitis, or less likely, a head and neck abscess. In the emergency room, the laboratory evaluation showed a white blood cell count of 18,600/mm2 with a 20% left shift in neutrophils. She had a C-reactive protein of 4.6 mg/dL. Intrvenous fluids were started and she felt better. Her head tilt continued so a head computed tomogram was performed and the diagnosis of a left parapharyngeal abscess was made.

The patient’s clinical course showed that Otolaryngology was consulted and the patient admitted. She was given intravenous antibiotics and on day 2 had surgical drainage. She was discharged on day 5 and completed 2.5 weeks of antibiotics in total. She was having no problems at followup at 2 weeks post-op.

Case Image

Figure 122 – Axial image from a CT scan of the neck performed with intravenous contrast demonstrates a left sided parapharyngeal abscess with a low density, round, fluid-filled center. There was some associated mass effect on the airway.

Discussion

Deep neck space infections (DNSI) are not very common (estimated to be 4.6/100,000) but extremely important to have a high index of suspicion for.
The anatomy of DNSs is complex and covered by substantial amounts of superficial soft tissue making diagnosis difficult.
Additionally, children often cannot give more precise or accurate histories and can be difficult to examine> Most infections in children are in those < 6 years.
Lying within or adjacent to the DNS are numerous bones, blood vessels, nerves and other soft tissues. The spaces communicate between each other and therefore spreading can also occur including into the chest.

Complications of DNSI include:

  • Airway compromise
  • Jugular vein thrombosis (Lemierre’s syndrome)
  • Mediastinitis
  • Neural dysfunction
  • Osteomyelitis
  • Sepsis
  • Vascular erosion

In pediatric patients, the usual cause is pharyngitis or tonsillitis, whereas in adult patients the usual cause is odontogenic. However it is important to note that there are substantial numbers of cases (20-50%) that the etiology is not identified. Fortunately, DNSIs are less common because of antibiotics for treatment of respiratory illnesses and odontogenic problems.

Other causes of DNSIs include:

  • Cervical lymphadenitis
  • Congenital anomalies
    • Branchial cleft
    • Thyroglossal duct cysts
  • Foreign body
  • Trauma
  • Instrumentation – bronchoscopy, esophagoscopy
  • Intravenous drug use
  • Salivary gland obstruction or infection
  • Laryngopyocele
  • Mastoiditis
  • Thyroiditis
  • Malignant node or mass with necrosis/suppuration

The spread from the initial location can be from direct spread, lymphatic system, lymphadenopathy suppuration, or from communication with other DNSs. Peritonsillar abscesses (also known as quinsy) are the most common. Retropharyngeal and parapharyngeal abscesses generally are the next most common but their order depends on the study. Submandibular, buccal, and mixed infections (including Ludwig’s angina) are less common.

Evaluation usually includes some type of radiological imaging to rule out other entities and to better define the DNSI. Computed tomography is often used as it is usually available and quick to complete. Magnetic resonance imaging has better soft tissue visualization but may not be available and usually takes longer which may require sedation. Ultrasound has been used in some cases.

Patients are treated with broad spectrum antibiotics especially for mixed, polymicrobial infections with aerobic and anaerobic organisms. Streptococcus and Staphylococcus are more commonly cultured. Surgical treatment is considered primary treatment and used initially or after a period of antibiotics. Some patients have resolution without surgical intervention.

Learning Point
As noted above children may have minimal signs and symptoms for DNSI. Parapharyngeal abscesses can be difficult as they can have no obvious swelling, and little or no pain or trismus. Poor oral intake, fever and upper respiratory tract infection symptoms such as rhinorrhea or cough are common and can look like many common pediatric illnesses. Fever, sore throat and dysphagia are also common symptoms of presenting DNSI patients.

Other possible signs of DNSIs include:

  • Fever
  • Neck swelling or mass, particularly with asymmetry
  • Fluctuance
  • Lateral pharyngeal wall displaced medially
  • Posterior pharyngeal wall displaced anteriorly
  • Tachypnea or shortness of breath
  • Trismus (due to pterygoid muscle inflammation)
  • Voice change
  • Referred pain – ear pain, headache, neck pain
  • Neural deficits – especially cranial nerves such as Horner syndrome, or vocal cord paralysis and hoarseness
  • Torticollis (due to inflammation of paraspinal muscles)

Questions for Further Discussion
1. What are indications for referral to otorhinolaryngology?
2. What antibiotics would you choose for empiric treatment of DNSIs?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Abscess

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Raghani MJ, Raghani N. Bilateral deep neck space infection in pediatric patients: review of literature and report of a case. J Indian Soc Pedod Prev Dent. 2015 Jan-Mar;33(1):61-5.

Lawrence R, Bateman N. Controversies in the management of deep neck space infection in children: an evidence-based review. Clin Otolaryngol. 2017 Feb;42(1):156-163.

Corte FC, Firmino-Machado J, Moura CP, Spratley J, Santos M. Acute pediatric neck infections: Outcomes in a seven-year series. Int J Pediatr Otorhinolaryngol. 2017 Aug;99:128-134.

Hah YM, Jung AR, Lee YC, Eun YG. Risk factors for transcervical incision and drainage of pediatric deep neck infections. J Pediatr Surg. 2017 Jun 27. pii: S0022-3468(17)30396-2.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa