Red Book Online Presents: Diagnosis Detective | September 2024
Editor: Kristina A. Bryant, MD, FAAP
Case contributed by Joana Coelho, MD, Cohen Children’s Medical Center, Queens, NY
A 14-year-old previously healthy female presents with 7 days of left-sided facial and neck swelling and tender cervical lymphadenopathy. She complains of fevers, odynophagia, generalized fatigue, headache, and photophobia. Symptoms began soon after the patient was physically assaulted and punched on the left side of her face. She has multiple healthy pets at home, including cats, dogs, and one rabbit. The patient vapes and has used marijuana; she engages in unprotected sexual activity with a male partner. She has not traveled outside the state of New York.
On presentation, her temperature is 39.9˚C (103.8˚F). Her heart rate is rapid at 144 beats per minute. Her respiratory rate is 26, blood pressure 110/72 mm/Hg, and oxygen saturation is 96% in room air. Her exam is notable for tender, left anterior cervical lymphadenopathy with the largest node measuring two centimeters in diameter. She has halitosis and dysphonia. Visualization of the oropharynx is limited due to trismus. A CT scan of the head and neck with intravenous contrast reveals multiple dental caries, swelling of the left palatine tonsil without a drainable fluid collection, and, as seen in Figure 1, complete occlusion of the left internal jugular vein.
Figure 1. CT scan of the head and neck with IV contrast, transverse image. The bilateral internal jugular veins are indicated by the blue and red arrows. The right internal jugular vein (lower left, blue arrow ) appears white due to presence of contrast, suggesting patency, while the left internal jugular vein (lower right, red arrow) appears gray due to absence of contrast, as well as presence of an air-fluid level, suggesting occlusion.
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