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Diagnostic Dilemma. (News).

A 4-year-old girl presents with a 3-day history of increasing fever, sore throat, difficulty swallowing, a "muffled" voice, and pain upon fully opening her mouth (see below). She has a temperature of 102.2[degrees]F and a respiratory rate of 25. An examination reveals somnolence, retractions, dysphonia, and cervical lymphadenopathy. She also has stridor. How would you approach this case?

A 4-year-old girl presents with a fever of 102.2[degrees] F, sore throat, difficulty swallowing, a "muffled" voice, and pain upon fully opening her mouth. The anterior cervical lymph nodes are enlarged, and she also shows dysphonia, retractions, and somnolence. (See p. 2 for a more complete history.)

SHORT DIFFERENTIAL DIAGNOSIS:

You suspect the following possibilities.

* Mononucleosis.

* Group A streptococcal disease.

* Tracheitis.

WORK-up: There are multiple infectious causes of fever, sore throat, dysphonia, and stridor to consider before proceeding with diagnostic measures.

When a child presents with dysphonia and lymphadenopathy, always consider viral and bacterial infections such as mononucleosis and group A streptococcal infection.

Less commonly, these symptoms may indicate neoplasm or drug allergies.

Ask what drugs the child has taken recently.

Stridor indicates a high degree of laryngeal or tracheal obstruction and may indicate diseases such as rare epiglottitis caused by Haemophilus influenzae.

In this illness, the epiglottis becomes swollen, resulting in obstructed breathing.

Tracheitis is another possibility if there is swelling in the area below the vocal cords.

TESTING: Order a CBC, a rapid strep test, mono spot, and blood culture to check for infection.

An x-ray film can help tell whether the epiglottis is swollen.

In this case, a CBC revealed a hemoglobin blood count of 11.9 and a WBC count of 11.5.

The rapid strep test was negative. A blood culture showed no growth, but the mono spot was positive.

A lateral neck x-ray quickly established that there was an enlarged tonsil--an early feature of mononucleosis.

There was no swelling in the epiglottis (ruling out epiglottitis), the vocal cord area (ruling out croup), or the area below the vocal cords (ruling out tracheitis).

The signs and symptoms in this patient were due to an enlarged, inflamed, exudative, and hemorrhagic tonsil caused by infectious mononucleosis.

The inspiratory stridor was the result of airway obstruction by severe tonsillitis.

FINAL DIAGNOSIS: Mononucleosis.

TREATMENT: Most patients recover from mononucleosis with 4-6 weeks of rest, without drugs.

At times, corticosteroid drugs are required to reduce severe inflammation that compromises the airway.

This patient was treated with intravenous fluids and two doses of intravenous Solu-Medrol.

The following morning she was considerably better, her left tonsil had diminished to approximately half its previous size, and she could swallow much better. She was discharged that morning.

Dr. Joseph A. Zenel Jr. of the Oregon Health & Science University, Portland.

If you would like to comment on this case or if you would like to offer an unusual case of your own for publication, you can write to PEDIATRIC NEWS at 12230 Wilkins Ave., Rockville, MD 20852; fax to 301-816-8738; or e-mail to pdnews@imng.com.
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Author:Zenel, Dr. Joseph A., Jr.
Publication:Pediatric News
Article Type:Brief Article
Date:Sep 1, 2002
Words:504
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