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Clinical Problem Solving: Radiology
May 2002

Radiology Quiz Case 2

Author Affiliations
 

R. NICKBRYANMDS. JAMESZINREICHMD

Arch Otolaryngol Head Neck Surg. 2002;128(5):597. doi:

A PREVIOUSLY HEALTHY 19-year-old man presented with an 8-day history of fevers, sore throat, and pain in his left ear. Four days before he presented, the results of a rapid streptococcal screen and a horse cell (Monospot) test were negative. Despite symptomatic therapy for presumed viral pharyngitis, his condition worsened; he developed progressive dyspnea and pleuritic chest pain as well as diffuse joint aches.

On physical examination, the patient was lethargic, with a temperature of 40°C, a pulse rate of 160 beats/min, a blood pressure reading of 115/44 mm Hg, and a respiratory rate of 36 breaths/min. Examination of his head and neck revealed mild posterior pharyngeal erythema and anterior cervical lymphadenopathy. There was no uvular deviation. Examination of his heart and lungs revealed no abnormalities. No murmurs were audible. His left knee was tender, with a moderate effusion. The results of his genitourinary and neurological examinations were normal. Laboratory tests revealed the following abnormalities: white blood cell count, 24 600/µL (75% neutrophils and 16% band cells); platelet count, 24 000/µL; sodium, 123 mg/dL; and creatinine, 1.4 mg/dL (124 µmol/L).

A chest radiograph (Figure 1) demonstrated multiple bilateral nodular opacities. Within 24 hours, blood cultures became positive for gram-negative rods, later identified as Fusobacterium necrophorum. A computed tomographic scan of the neck (Figure 2) revealed thrombosis of the left internal jugular vein and a fluid collection measuring 22 × 25 × 40 mm in the left peritonsillar region. Direct laryngoscopy revealed purulent drainage within the peritonsillar fossa. Ligation and excision of a thrombosed internal jugular vein was necessary.

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