A 6-year-old girl is brought to the office by her parents due to swelling on the right side of her neck. Two weeks ago, the patient's mother first noticed a mass on her daughter's neck; although the mass size remains unchanged, it has become more painful. Initially, her parents tried to treat the pain with ibuprofen and warm compresses, but with minimal relief. A 7-day course of oral clindamycin resulted in no improvement. The mass has become so painful that the patient is unable to fall asleep and tries not to turn her head. Today, she reports a foreign body sensation in her eyes and increased tearing. She has had increased fatigue and decreased appetite but no fever, weight loss, or difficulty swallowing. The patient has environmental allergies and seborrhea. She has a kitten and 2 hamsters. Temperature is 37.2 C (99 F). Examination of the right eye shows injected conjunctivae and scant clear discharge. The left eye is unaffected. Tympanic membranes are clear bilaterally. The posterior oropharynx is clear and without erythema or exudates. There is a 3-cm (1.2-in), tender, indurated, mobile cervical lymph node and a smaller 1-cm, tender, preauricular lymph node, both on the right side of the neck. Which of the following complications is most likely to develop in this patient?

Question

A 6-year-old girl is brought to the office by her parents due to swelling on the right side of her neck.  Two weeks ago, the patient's mother first noticed a mass on her daughter's neck; although the mass size remains unchanged, it has become more painful.  Initially, her parents tried to treat the pain with ibuprofen and warm compresses, but with minimal relief.  A 7-day course of oral clindamycin resulted in no improvement.  The mass has become so painful that the patient is unable to fall asleep and tries not to turn her head.  Today, she reports a foreign body sensation in her eyes and increased tearing.  She has had increased fatigue and decreased appetite but no fever, weight loss, or difficulty swallowing.  The patient has environmental allergies and seborrhea.  She has a kitten and 2 hamsters.  Temperature is 37.2 C (99 F).  Examination of the right eye shows injected conjunctivae and scant clear discharge.  The left eye is unaffected.  Tympanic membranes are clear bilaterally.  The posterior oropharynx is clear and without erythema or exudates.  There is a 3-cm (1.2-in), tender, indurated, mobile cervical lymph node and a smaller 1-cm, tender, preauricular lymph node, both on the right side of the neck.  Which of the following complications is most likely to develop in this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf87_2c6d_8f63_eb6f107f3fb7_MD0005_00 This patient has cervical and preauricular adenopathy as well as unilateral conjunctivitis. Given the history of kitten exposure, she most likely has oculoglandular syndrome (Parinaud oculoglandular syndrome), a specific manifestation of cat-scratch disease (CSD). CSD is caused by infection due to Bartonella henselae, a small gram-negative rod carried by cats, especially kittens. Human transmission most commonly occurs through a cat bite or scratch, although many patients do not remember the exact point of contact. CSD typically presents with lymphadenitis and is the most common cause of chronic (>2 weeks), unilateral adenitis in children. Since bites and scratches usually occur on the extremities, ipsilateral axillary or inguinal node involvement is most common. However, when the inoculation is near the face, adenopathy of the preauricular or cervical nodes is seen. Involvement of the conjunctivae (as in this case) is an uncommon but characteristic presentation of CSD. Symptoms typically self-resolve within a couple of months; however, in some cases, lymph nodes will suppurate and drain onto the skin. Treatment with azithromycin can help accelerate recovery, and needle aspiration may prevent overt rupture and relieve symptoms; lymph node excision is not indicated. (Choice A) Coronary artery aneurysms are a serious complication of Kawasaki disease (KD), which can also present with cervical adenitis. However, fever, mucous membrane changes, and rash are other common features of KD that are not present in this patient. In addition, conjunctivitis associated with KD is bilateral and limbic-sparing, not unilateral. (Choice B) Adenovirus can cause cervical adenopathy and severe conjunctivitis, which may progress to overt keratitis and visual impairment. However, presentation usually also includes pharyngitis and fever (not present in this patient), and symptoms typically last less than a week. (Choice D) Mycobacterium tuberculosis can present as chronic, unilateral cervical lymphadenopathy (ie, scrofula) and, if left untreated, will progress to lower respiratory tract disease including pneumonia, hilar adenopathy, and pleural effusions. However, tuberculosis does not cause preauricular adenopathy or conjunctivitis, and this patient has no fever, cough, or weight loss. (Choice E) Splenic rupture is an uncommon but serious sequela of infectious mononucleosis due to Epstein-Barr virus infection. Mononucleosis may present with chronic bilateral cervical adenopathy, but patients usually have pharyngitis, fever, and splenomegaly, none of which are present in this patient. Educational objective: Oculoglandular syndrome is a specific presentation of cat-scratch disease characterized by conjunctivitis and ipsilateral preauricular and cervical adenopathy. The most common complication of cat scratch disease is lymph node suppuration. References: Cat-scratch disease. (http://www.ncbi.nlm.nih.gov/pubmed/21243990) Ocular manifestations of bartonella infection. (http://www.ncbi.nlm.nih.gov/pubmed/28984726)

A 6-Year-Old Girl Is Brought to the Office by Her