Febrile toddler presents with painful neck mass
What’s your diagnosis?
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A 16-month-old girl presents with a painful neck mass and fever. Her mother states that she has always had a “fullness” in the front of her neck, which suddenly increased in size. She had actually been told about 7 months ago that it needed surgery. However, her mother did not follow up as instructed.
Examination revealed an alert but fussy, febrile (102.3°F or 39°C) toddler with discrete swelling in the anterior neck, in the midline (Figure 1). The lesion is soft with shiny, erythematous overlying skin.
What’s your diagnosis?
A. Actinomycosis
B. Nontuberculous mycobacteria
C. Submental adenitis
D. Thyroglossal duct abscess
Answer and discussion:
The answer is thyroglossal duct abscess — choice D. As a result of a congenital malformation during the process of thyroid development, the thyroglossal duct that develops in the fetus as the thyroid migrates to the anterior neck persists instead of obliterating, which is what normally happens. A cystic lesion can be left behind, called the thyroglossal duct cyst. It may be noticed as a soft, painless swelling. About 50% of those with this malformation go through life unaware that they have it. However, oral bacteria may enter and result in an infection, setting the stage for an abscess to form. In this vignette, the patient underwent incision and drainage, recovering a large amount of pus that grew Staphylococcus aureus (Figure 2). After recovery, the patient returned to have the defect removed.
Actinomycosis is an infection caused by a species of the Actinomyces genus, usually A. israelii, a gram-positive, anaerobic rod that is usually a normal oral commensal but can become an opportunistic pathogen. In the mouth, it usually involves poor hygiene or a break in the barrier. Untreated, the infection may progress with breakthrough infection that drains from a location within the oral cavity through to the overlying skin via the sinus tract (Figure 3). Penicillin is the first drug of choice for treatment, but various tetracyclines will also work.
Nontuberculous mycobacteria is a fairly common cause of lymphadenitis of the neck, most commonly Mycobacteria avium complex group (Figure 4). The best treatment is complete surgical excision, with or without drugs. Clarithromycin, possibly with rifampin, can be used to help limit spread (see Nelson’s Pocketbook of Pediatric Antimicrobial Therapy, 2021 edition).
A submental abscess would likely originate in the submental lymph node, in the midline just under the chin, not over the area of the thyroid.
Tip: Any time you encounter a lesion with overlying skin that is shinny and erythematous, you can count on underlying pus.
Columnist comments
I would like to offer tributes to two giants in their respective fields.
The first is my old friend, Phil Brunell, MD, who died at 91 years of age (Feb. 1, 1931 – Jan. 29, 2023). While the following relies on my own feeble memory, I recall the following in reasonable detail. A real obituary could not be found. I must begin by noting that Phil was the founding medical editor of Infectious Diseases in Children (IDC). While walking together to the Los Angeles Convention Center from the Hotel Figueroa, the conversation turned to IDC. He soon asked if I would begin writing the column, What’s Your Diagnosis? I agreed, and my first column was on cat scratch disease in the April 1989 issue (34 years ago).
We first met when I finished my fellowship and was assigned to Brooke Army Medical Center in San Antonio. Phil was the head of the pediatric ID section of the University of Texas Health Science Center, prior to moving to LA. During his San Antonio years, he led the fellowship program and aggressively pursued teaching at every opportunity, including leading the weekly citywide “Bug Club” every Wednesday. Phil was the chair of the Red Book committee in 1986, and served in the capacity of committee member as well as advisor to the chairperson throughout the 1980s. He was the leading authority in the area of varicella virus and disease, with great depth across all areas of infectious diseases. It was a regrettable day when Phil left San Antonio for a position at Cedars-Sinai Medical Center in LA. After retiring from Cedars-Sinai, he moved to Chevy Chase, Maryland, and continued in a volunteer capacity at the NIH and the Uniformed Services University of the Health Sciences in Bethesda. I owe Dr. Brunell more than I can ever repay, especially during my early years in San Antonio.
To learn more about Dr. Brunell in his own words, I recommend this farewell message from him after 22 years as IDC’s chief medical editor.
William Weston, MD, died at 84 years of age (Aug. 13, 1938 – Nov. 13, 2022). In 1979, Weston wrote an outstanding pediatric dermatology book with the general pediatrician in mind (Practical Pediatric Dermatology). I bought it during my third year of residency and took it with me on an elective rotation with Dr. Weston, who was the chair of dermatology at the University of Colorado School of Medicine. Dr. Weston had a reputation for excellence, as well as a somewhat gruff personality, and friends recommended not asking too many questions. However, I was undeterred, and dove in. My first question was “Why were all the pictures in this outstanding textbook in black and white?” Expecting a “sharp reaction”, he politely said that he wanted to emphasize a verbal description of the skin condition, rather than simply looking at a color picture and trying to match it up with the patient at hand. While that was a meritorious answer, I also figured it had to do with the cost of publishing color prints. His second book, Color Textbook of Pediatric Dermatology, was published in 1991 (I like to think that I had something to do with this transition to color). His second edition of that book was published in 1996, and that is the one I have. I might point out that an addition to this most recent book is the “problem-oriented differential diagnosis index,” which is laid out in an easy-to-read list that uses the pastedown endpapers in the front and back, as well as both free endpapers. The topics are broken down by categories, which makes getting to the subject faster. I have not seen this style utilized in any other book that I own.
Many years later, Dr. Weston and I were speaking at the same meeting in San Antonio. After attending his session, I went to the front of the room to see him. He very graciously remembered me and complimented me after having already attended my session. His compliment remains one of my professional highlights.
Click here to read Dr. Weston’s obituary in the Denver Post, outlining his remarkable life.
References:
Kimberlin DW, et al., eds. Red Book 2021: Report of the Committee on Infectious Diseases. Academy of Pediatrics; 2021. https://redbook.solutions.aap.org/redbook.aspx. Accessed May 8, 2021.
Bradley JS, Nelson JD, eds. Nelson’s Pediatric Antimicrobial Therapy. 27th Edition. American Academy of Pediatrics, 2021. https://seciss.facmed.unam.mx/wp-content/uploads/2021/01/1700.pdf. Accessed May 8, 2021.
Weston WL. Practical Pediatric Dermatology. Little Brown & Co., 1985. https://www.biblio.com/book/practical-pediatric-dermatology-little-brown-series/d/1401905071. Accessed May 8, 2021.
Weston WL, et al. Color Textbook of Pediatric Dermatology. 2nd ed. Mosby Inc., 1997. https://www.jaad.org/article/S0190-9622(98)70191-4/fulltext. Accessed May 8, 2021.
For more information:
Brien is a member of the Healio Pediatrics Peer Perspective Board and an adjunct professor of pediatric infectious diseases at McLane Children's Hospital, Baylor Scott & White Health, in Temple, Texas. He can be reached at jhbrien@aol.com.