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Diagnosis Detective - March 2024

March 6, 2024

Red Book Online Presents: Diagnosis Detective | March 2024

Contributed by Kristina A. Bryant, MD, FAAP, Committee on Infectious Diseases

An 18-month-old girl presents to a pediatric emergency department with a 3-day history of fever, sore throat, and bilateral cervical lymph node swelling. Testing at her pediatrician’s office one day earlier included negative nucleic acid amplification tests (NAAT) for group A Streptococcus, influenza, and SARS-CoV-2. She now complains of difficulty swallowing. Physical examination reveals an ill-appearing child with a thick grey coating on both tonsils (similar to the image below), mucopurulent nasal discharge tinged with blood and markedly enlarged, tender cervical lymph nodes bilaterally. An 11-year-old cousin arrived from Nigeria 1 week ago and has similar symptoms.

The child’s history is remarkable for immunization lag. According to the state immunization registry, she received age-appropriate immunizations at 2 months of age and none since.

Child's open mouth, with adult hands on either side using tongue depressors to see inside the throat.

© 2024 American Academy of Pediatrics. All rights reserved.

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