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Diagnosis Detective - February 2025

February 3, 2025

Diagnosis Detective: Can you solve it?
Red Book Online Presents: Diagnosis Detective | February 2025

Editor: Kristina A. Bryant, MD, FAAP

Case contributed by Ugur Berkay Balkanci, MD, MPH, Children's National Hospital, Washington, DC

A 5-year-old previously healthy female presents with 2 weeks of left axillary swelling and pain. Her family describes night sweats but denies fevers or weight loss. Her symptoms were persistent despite a 10-day course of amoxicillin for presumed lymphadenitis. On physical examination, she has left axillary lymphadenopathy that is tender and warm to touch without overlying color changes or drainage. No other lymph nodes are palpable.

The child’s diagnostic evaluation prior to presentation included an interferon gamma release assay (IGRA), Epstein Barr virus and cytomegalovirus serologies, Lyme serologies, Bartonella whole blood DNA PCR, and a blood culture. All test results were negative. An ultrasound demonstrated a 3.0 x 2.4 x 1.6 cm complex partially loculated fluid collection in the left axilla with multiple nearby reactive lymph nodes.

Six weeks earlier, the child had visited a family member who has dogs, several kittens, and chickens. No bites or scratches were noted during or after the visit. Her immunizations are up to date.

A picture of her left axillary area appears below.

A close-up image of a child's underarm area showing a prominent swelling or lump beneath the skin. The swelling appears smooth and is distinctly raised from the surrounding skin.

© 2025 American Academy of Pediatrics. All rights reserved.


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