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Clinical Challenge
March 2016

Facial Swelling in an Infant

Author Affiliations
  • 1University of Texas Medical School at Houston, Department of Pediatrics, Houston
  • 2University of Texas Medical School at Houston, Medical School, Houston
JAMA Otolaryngol Head Neck Surg. 2016;142(3):293-294. doi:10.1001/jamaoto.2015.3197

A 5-month-old, previously healthy girl presented with a 1-month history of recurrent, right-sided facial swelling. Her mother first noticed the swelling 3 to 4 days after the infant received her 4-month vaccines. At that time, the patient's right buccal and mandibular soft tissues were swollen and erythematous. She had accompanying fever and nonbilious, nonbloody vomiting and was taken to a community emergency department where she was observed overnight and discharged with an antibiotic and a diagnosis of right-sided parotitis. Initially, the facial swelling improved with antibiotics; however, within days of completing the antibiotic, it returned, now extending superior beyond the original borders to include the right infraorbital area. The parents denied any facial trauma. On transfer to an academic children’s hospital, the infant was afebrile, alert, and appeared comfortable. The right side of her face was swollen from the infraorbital rim to the submandibular area, including the buccal soft tissue. The area of swelling was not indurated or erythematous. The right mandible was very tender to palpation as noted by profound irritability on examination of the area. She had no bruising or other external signs of trauma (Figure, A). She had a white blood cell count of 19 200/μL with a differential of 6912/μL neutrophils, 0/μL bands, 11 712/μL lymphocytes, and 192/μL monocytes; a platelet count of 610 ×103/μL; and a C-reactive protein level of 112 mg/L. A computed tomographic (CT) scan of the head and magnetic resonance images (MRI) scans of the face are shown in the Figure, B-D.

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