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A 7 year old Child, recent immigrant from eastern  Europe presented with 4 
days of right neck swelling.
He was seen by his PMD 2 days prior had a throat culture which was positive 
 for strep and discharge on amoxil.
In our ER he was afebrile, had a very hard slightly erythematous,  tender 
mass starting behind his right ear, going down his right neck. 
He also had a stiff neck, holding it straight up. The rest of the exam was  
normal
I assumed he had staph/strep lymphadenitis and we debated whether IV Clinda 
 in the ER with next day follow up is OK or maybe we should admit him.
We then did an ultrasound which showed multi loculated abscesses, on  
sitting very close to the right carotid artery.
Worried about the location of this abscess we did a neck CT (with  
contrasrt) which confirmed the presence and location of the abscess but  also showed 
a right internal jugular vein totally clotted from the bifurcation  (with 
the subclavian) to the level of the angle of C2. The child was  obviously 
admitted and is being treated (Lemierre's syndrome ?).
 
Now, I have seen zillion children with large cervical  lymphadenitis, I do 
not  use ultrasound on many  ( we had none until a  few years ago...) and 
certainly do not CT their neck  routinely.
And now I am asking myself, did I miss those cases  before, was I just 
lucky that no one ended up septic, I was certainly lucky  here!
did any one of you have a similar  case?
 
Giora Winnik MD
Maimonides MC, Brooklyn NYC
 

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