USMLE Forum Archives - USMLE Step 3 - A 40-Day-Old Boy With Facial Swelling
A 40-Day-Old Boy With Facial Swelling
zkadhem - 06-12-09 11:20
A 40-day-old white male infant with a previously uncomplicated neonatal course presents with a 2-day history of expanding swelling and erythema involving the left angle of the mandible. The infant has been irritable and inconsolable for the 12 hours before presentation. His parents are very distraught. They tried feeding, rocking, and burping the infant, but nothing relieved the crying. According to the parents, the patient had a fever on the day before admission. The infant was a 7.5-lb (3.4-kg), term baby delivered via normal, spontaneous vaginal delivery to a 26-year-old mother who was positive for group B Streptococcus (GBS), rubella-immune, and negative for hepatitis B surface antigen. Rupture of the membranes occurred 10 hours before delivery, with clear fluid. The intrapartum medications included 2 doses of clindamycin for the positive GBS test, which was performed at 35 weeks of gestation. There was no perinatal maternal fever. The Apgar scores were 8 and 9 at 1 and 5 minutes, respectively.
The physical examination shows an irritable infant with a rectal temperature of 101.5°F (38.6°C). In the emergency room, the infant has a heart rate of 120 bpm, a respiratory rate of 48 breaths/min, and a blood pressure of 100/58 mm Hg. A 4-cm area of indurated, nonfluctuant, tender swelling and erythema involving the left subauricular and submandibular facial areas and extending along the line of the jaw to the chin is noted (see Figure 1). The floor of the mouth is soft and the uvula is midline and not enlarged. There is no pharyngeal erythema or exudates. No rhinorrhea is evident. The fontanelle is soft and flat. The lungs are clear to auscultation bilaterally and there are no retractions or nasal flaring. No heart murmur is detected and the heart sounds are normal. The rest of the physical examination is unremarkable.
The peripheral leukocyte count at admission is 10.2 × 103/mm3 (10.2 × 109/L), with 13% bands, 61% neutrophils, 13% lymphocytes, and 3% monocytes. Sodium, chloride, potassium, and bicarbonate are within normal limits for the patient's age. A lumbar puncture is performed and reveals cerebrospinal fluid (CSF) with protein of 67 mg/dL, glucose of 59 mg/dL, leukocytes of 2/mm3, and no red blood cells. Gram stain and agglutination studies are negative. The urine analysis and urine culture results are unremarkable.
What is the most likely diagnosis?
zkadhem - 06-12-09 11:20
A 40-day-old white male infant with a previously uncomplicated neonatal course presents with a 2-day history of expanding swelling and erythema involving the left angle of the mandible. The infant has been irritable and inconsolable for the 12 hours before presentation. His parents are very distraught. They tried feeding, rocking, and burping the infant, but nothing relieved the crying. According to the parents, the patient had a fever on the day before admission. The infant was a 7.5-lb (3.4-kg), term baby delivered via normal, spontaneous vaginal delivery to a 26-year-old mother who was positive for group B Streptococcus (GBS), rubella-immune, and negative for hepatitis B surface antigen. Rupture of the membranes occurred 10 hours before delivery, with clear fluid. The intrapartum medications included 2 doses of clindamycin for the positive GBS test, which was performed at 35 weeks of gestation. There was no perinatal maternal fever. The Apgar scores were 8 and 9 at 1 and 5 minutes, respectively.
The physical examination shows an irritable infant with a rectal temperature of 101.5°F (38.6°C). In the emergency room, the infant has a heart rate of 120 bpm, a respiratory rate of 48 breaths/min, and a blood pressure of 100/58 mm Hg. A 4-cm area of indurated, nonfluctuant, tender swelling and erythema involving the left subauricular and submandibular facial areas and extending along the line of the jaw to the chin is noted (see Figure 1). The floor of the mouth is soft and the uvula is midline and not enlarged. There is no pharyngeal erythema or exudates. No rhinorrhea is evident. The fontanelle is soft and flat. The lungs are clear to auscultation bilaterally and there are no retractions or nasal flaring. No heart murmur is detected and the heart sounds are normal. The rest of the physical examination is unremarkable.
The peripheral leukocyte count at admission is 10.2 × 103/mm3 (10.2 × 109/L), with 13% bands, 61% neutrophils, 13% lymphocytes, and 3% monocytes. Sodium, chloride, potassium, and bicarbonate are within normal limits for the patient's age. A lumbar puncture is performed and reveals cerebrospinal fluid (CSF) with protein of 67 mg/dL, glucose of 59 mg/dL, leukocytes of 2/mm3, and no red blood cells. Gram stain and agglutination studies are negative. The urine analysis and urine culture results are unremarkable.
What is the most likely diagnosis?
The correct answer and explanation will be available after you answer.
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#19
Re: A 40-Day-Old Boy With Facial Swellin conym5 - 04-12-10 08:36 Cellulitis-adenitis syndrome is a disease of great concern because there is a potential for upper airway obstruction and septic shock, which may lead to significant morbidity and mortality.
#26
Re: A 40-Day-Old Boy With Facial Swellin babbu5508 - 08-31-10 05:23 My answer is: d.
Cellulitis-adenitis syndrome is a rare clinical manifestation of group B Streptococcus (GBS) late-onset disease. Its significance lies in the fact that local infection may be the only initial sign of systemic infection that is often concurrent with meningitis.
#30
Re: A 40-Day-Old Boy With Facial Swellin babbu5508 - 09-24-10 06:11 Cellulitis-adenitis syndrome is an established but uncommon presentation of group B streptococcus (GBS) infection in neonates and young infants
#37
Re: A 40-Day-Old Boy With Facial Swellin tesbenzon - 07-24-11 05:07 My answer is: a.
Blood picture suggest viral infection
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