A 3-year-old boy is brought to the office due to nasal discharge for the past 2 weeks. His mother reports whitish nasal discharge that has become progressively thicker and more malodorous. The patient has had no fever, cough, or shortness of breath. He is eating normally. Medical history includes congenitally acquired HIV, and the patient has taken antiretroviral therapy since birth. Three months ago, CD4 cell count was 520/mm³. He has received all age-appropriate vaccinations. The patient lives with his parents, 6-year-old brother, and a pet dog. His father smokes cigarettes outside of the house. Growth parameters are at the 40th percentile for age. On examination, the patient is playful and interactive. There is purulent drainage from the right nostril, and the right nasal mucosa and turbinates are erythematous and swollen. There is no discharge from the left side, and the left turbinates are pink and nonedematous. The oropharynx and tonsils are normal. There is no cervical lymphadenopathy. Which of the following is the most likely cause of this patient's current symptoms?

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11ec25c8_d654_7971_bc81_03c08998e9e9_MD0003_00 This toddler with unilateral purulent rhinorrhea likely has an intranasal foreign body. Most intranasal foreign bodies occur in children age 1-6, and the variety of objects found is virtually endless. Patients with comorbidities (eg, HIV) are still at risk for typical childhood ailments, and in patients with well-controlled infections, this is more likely. The diagnosis is usually straightforward. However, insertion of the intranasal foreign body is unobserved by the caregiver in 25% of cases. In these patients, the retained object can induce inflammation (eg, nasal turbinate erythema) or become infected, leading to unilateral purulent discharge. Patients may also have sneezing or epistaxis. Imaging is not helpful because most objects are radiolucent. The object can usually be seen and safely removed in the office. However, if the object cannot be visualized because of its location or surrounding purulent secretions or if removal could cause further trauma (eg, penetrating objects), referral to otolaryngology is appropriate. Nasal foreign bodies should not be managed expectantly because the resultant inflammation may lead to obstruction of the sinus outflow tract and cause sinusitis or periorbital cellulitis. (Choice A) Acute bacterial sinusitis can present with purulent nasal drainage and inflamed nasal mucosae. However, nasal symptoms are typically bilateral and accompanied by fever, cough, and an ill appearance. (Choice B) Adenoidal hypertrophy, the most common cause of nasal obstruction in children, can result in mucopurulent nasal discharge; however, symptoms are typically bilateral. (Choice C) Allergic rhinosinusitis can present with rhinorrhea in a well-appearing child. Parental smoking increases this risk, and pets can be a source of antigen exposure. However, in contrast to this patient, symptoms of allergic rhinosinusitis are typically bilateral, rhinorrhea is clear, and the turbinates appear bluish or pale. (Choice D) The frontal sinuses are absent at birth and progressively pneumatize from age 2 through puberty. Frontal sinus agenesis can occur, but it is asymptomatic. (Choice F) Mucormycosis (invasive fungal sinusitis) can present in immunocompromised patients (eg, CD4 count <50/mm³) with nasal obstruction and rhinorrhea. Invasion of blood vessels by fungal hyphae leads to ischemia (white nasal turbinates) and necrosis (black nasal turbinates). Educational objective: Unilateral, purulent rhinorrhea in a young child is often due to a retained intranasal foreign body. References: Foreign bodies in the ear, nose, and throat. (http://www.ncbi.nlm.nih.gov/pubmed/17990843)

A 3-Year-Old Boy Is Brought to the Office Due to Nasal