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Virtual Pediatric Patients
Donna M. D'Alessandro M.D., Tamra E. Takle M2
Peer Review Status: Internally Peer Reviewed
"My
son DeShawn is a really smart 3 year old. He sometimes gets into
things he shouldn't and gets in trouble for not listening, but he's a
pretty good kid. He's really active - he usually gets up at about 7
AM, and after breakfast he disappears outside to ride his little bike
or play with his brothers and sisters. He plays outside in front of
the house most of the day. He talks a lot too, so when he's quiet or
not acting like himself, I know something is wrong."
The Problem / Clinical Presentation
"DeShawn
spent the night at his godmother's house 2 days ago, and the next
morning when she brought him home, he said his ear was hurting. He
had a headache and fever, and wasn't very active. I asked which ear
hurt, and he pointed to both of them. I called his pediatrician, and
the nurse told me to bring him in. They checked him over, and at
first they told me he had a special kind of ear infection, so they
had to put a needle into his spine to make sure he didn't have
meningitis. They admitted him to the hospital to keep an eye on him
yesterday, but he got worse. He was breathing so loud that it sounded
like he was snoring, and complained that his neck hurt. So his
pediatrician arranged to bring him to Iowa City in the helicopter. It
just happened so suddenly; I didn't think DeShawn was that sick."
Clinical Physical Exam
Upon arrival at the University of Iowa, DeShawn was quiet but
obviously uncomfortable and stridorous. He was afebrile with stable
vital signs. Respiratory rate was 24 per minute. HEENT examination
revealed his nose to have greenish discharge. Tonsils were enlarged
without exudates with left greater than right and deviation of the
uvula to the right. His airway was patent. His neck revealed a
painful left anterior cervical and subauricular area with fullness.
He had shotty bilateral anterior cervical adenopathy. His lungs were
clear and the rest of his physical examination was normal.
Clinical Differential Diagnosis
Clinical Labs
His CBC showed a hemoglobin of 10.4 g/dl, hematocrit 28%, platelets
329K/mm3. A WBC of 24.1 K/mm3 was high. His peripheral smear showed a
normal differential, with a left shift of 75% PMNs and marked toxic
granulations. His electrolytes were normal. Blood culture showed no
growth. Iron studies were consistent with an iron deficiency anemia.
Laboratory Differential Diagnosis
In addition to this, the clinical differential diagnosis is unchanged.
Imaging Findings
A
lateral radiograph of DeShawn's neck revealed the retropharyngeal
space to be dramatically enlarged from the level of the nasopharynx
to just above the thoracic inlet. The computed tomography scan of his
neck showed prominent retropharyngeal soft tissues and left tonsil
causing mass effect on the airway.
Imaging Differential Diagnosis
Left tonsillar and retropharyngeal abscess
Operative Intervention
No operative intervention was performed
Pathological Findings
Not applicable
Pathological Diagnosis
Not applicable
Treatment Course, Prognosis and Follow-up
He was taken to the Pediatric Intensive Care Unit (PICU) for
continuous observation of his respiratory status and was given IV
antibiotics. He never required intubation or surgical intervention
and had resolution of his symptoms by day 2 so that he could be
transferred to the floor. Daily bedside laryngoscopies were performed
to document the resolving abscess. He also had a repeat computed
tomography scan on day 4 which showed almost complete resolution. He
will be sent home on oral antibiotics and iron.
"The doctors said DeShawn was really lucky he didn't have to go to the operating room. He's done really well, and he liked all the popsicles they gave him to eat. When he goes home, he'll still have to take some medicine and see his doctors in a few days, but he should be just fine."
Sore throat is a very common illness. Often it is mild and self-limited but may be the initial symptom of a severe illness with spread of infection into adjoining tissues. Inflammation of the tonsils, pharynx and surrounding tissues can be quite painful.
Differential Diagnosis
Commonly the differential diagnosis is between group A beta-hemolytic streptococcus and a viral pharyngitis. Depending on the age, history and physical examination, other diagnoses should be considered.
Infectious
Viral
Fungal
Other Causes
History and Physical Exam
History should include onset of the symptoms, severity, and associated symptoms such as fever, rash, headache, nausea/emesis, and abdominal pain. Fever is often associated with sore throat, as well as behavioral changes or decreased activity. An exposure history including contact with ill persons, especially to group A beta-hemolytic streptococcus, is important.
Physical examination should document the fever and proceed with a careful examination of the pharynx and neck for erythema, exudates, ulcerations and evidence of inability to swallow or difficulty in breathing. Additionally, upper respiratory infection (URI) signs such as rhinorrhea may also be present. Cervical lymphadenopathy may be present with streptococcal disease or with URIs. Streptococcal disease will present with tender lymph nodes, palatal petechiae and tonsillar exudates with fever; typical URI features are enlarged lymph nodes that are non-tender, rhinorrhea, patients generally have no exudates and may have cobblestoning of the pharynx. A complete physical examination including dermatological examination for rashes and genitourinary examination for discharge should also be done.
Evaluation
The laboratory evaluation often includes a throat culture and/or a rapid antigen test for group A beta-hemolytic streptococcus. If other disease entities (especially invasive diseases) are being considered, prompt, appropriate evaluation and treatment are necessary. Below is a list of tests to consider.
Blood
Imaging
Other
Consultation
Treatment
Most children usually have a self-limited, localized infectious disease process. Viral pharyngitis and URIs should be treated symptomatically with fluids, humidity and anti-pyretics for comfort. Group A beta-hemolytic streptococcus can be confirmed by a positive rapid antigen test and treated with antibiotics if positive. Alternatively, a throat culture may be used and should always be done if a rapid antigen test is negative. Group A beta-hemolytic streptococcus is sensitive to penicillin, which is the drug of choice. Invasive disease should be treated promptly with attention to airway control. Drainage of abscesses and early initiation of appropriate antibiotic coverage is important.
Clinical Presentation
Clinical features of Retropharyngeal Abscess (RPA) are often
nonspecific, consisting of vague symptoms such as fever, fussiness,
sore throat, nonspecific neck stiffness and poor feeding. Later, the
child appears acutely ill with fever, upper airway compromise,
stridor, drooling and respiratory distress. Often the child may have
upper respiratory tract infection and be treated with antibiotics
before the diagnosis of RPA. Symptoms usually precede the diagnosis
by 5-6 days. Cervical lymphadenopathy and neck swelling
(retropharyngeal bulge) are important physical findings, but the
latter may not always be appreciated.
Pathophysiology
Retropharyngeal abscess is a potentially life-threatening upper
airway infection in children. Over 90% of cases present in children
under the age of 6, with a slight male preponderance. The
retropharyngeal space contains loose connective tissue and lymph
nodes, receiving drainage from adjacent bones and sinuses, teeth,
Eustachian tube, middle ear and nasopharynx. Lymphatic spread of
infection is common; other causes include direct spread from adjacent
areas, trauma or foreign bodies.
Lab Findings
Laboratory studies may reveal a leukocytosis, but a normal WBC does
not exclude the diagnosis of RPA. Blood cultures are usually
negative. Abscess cultures usually contain polymicrobes, such as
Staphylococcus aureus, streptococcal species, and anaerobes.
Imaging Findings
The
lateral neck radiograph will show thickening of the retropharyngeal
space with anterior displacement of the airway. Occasionally, gas can
be seen in the retropharyngeal soft tissues. Computed tomography
better delineates the abnormality, and better demonstrates walled off
abscess cavities.
Pathology
Not applicable
Differential Diagnosis
Treatment
Antibiotic therapy alone is successful in 15-25 percent of cases. For
patients who do not respond to antibiotics, surgical drainage is
warranted. For cases complicated by airway obstruction or severe
illness, endotracheal intubation and surgical drainage may be
necessary.
Prognosis
Prognosis is good assuming prompt institution of antibiotics,
surgical therapy if necessary, and appropriate supportive care.
References
Berkowitz, Carol D, Pediatrics A Primary Care Approach. W.B. Saunders
and Co. Philadelphia, PA, 1996. pp. 186-190.
Fleisher, Gary R, Ludwig, Stephen. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins, Baltimore, MD, 1996. pp. 243-245
Schroeder LL, Knapp JF. Recognition and emergency management of infectious causes of upper airway obstruction in children. Seminars in Respiratory Infections 1995: 10(1), 21-30.
Gagliana MJ, Edwards MS. Clinical indicators of childhood
retropharyngeal abscess. American Journal of Emergency Medicine 1995:
13(3), 333-336.
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