HISTORY
A 20-month-old boy brought to the emergency department with swelling on the right side of the neck and fever (temperature, 39.3°C [102.7°F]) of 1 day's duration. The parents reported that the child had had intermittent fevers and poor weight gain for the past 3 months but no vomiting, diarrhea, rash, drooling, or difficulty in swallowing.
Patient had had pneumonia 3 times since birth. Two maternal cousins had chronic granulomatous disease. No family history of travel outside the United States.
PHYSICAL EXAMINATION
Temperature at the time of admission, 37°C (98.6°F); heart rate, 132 beats per minute; respiration rate, 43 breaths per minute; oxygen saturation, 100% while breathing room air; and blood pressure, 95/51 mm Hg. Weight, 9.4 kg; height, 76.5 cm; and head circumference, 46 cm (all growth parameters less than the 5th percentile).
Soft, 3 × 2-cm mass on the right side of the neck, mildly tender on palpation. Large anterior cervical lymph nodes on the right side. Lungs, clear to auscultation. Heart rate and rhythm, regular without murmurs. Abdomen soft, nondistended, without hepatosplenomegaly.
LABORATORY AND RADIOGRAPHIC FINDINGS
White blood cell count, 16,700/μL; hemoglobin level, 8.6 g/dL; hematocrit, 27.5%; platelet count, 409,000/μL. CT scan of the neck revealed a large mass (possibly a collection of infected lymph nodes), bilateral cervical adenopathy, and possible fluid in the retropharyngeal space.
INITIAL TREATMENT
Intravenous clindamycin(Drug information on clindamycin) started for coverage for gram-positive and anaerobic organisms. Child became febrile over the next 48 hours. Incision and drainage of the mass was performed. Culture of the lymph nodes grew Serratia marcescens.
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