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Snapshot diagnosis - what's causing this painful neck swelling on an infant?

Dr Mike Wyndham describes how he got to the root of another puzzling presentation involving an infant with a painful neck swelling

Dr Mike Wyndham describes how he got to the root of another puzzling presentation involving an infant with a painful neck swelling

The patient

This 18-month-old boy had only previously visited our surgery for his routine immunisations.

His mother explained that he had not been well over the previous 48 hours with loss of appetite, fever and increasing highly uncharacteristic sleepiness.

On the day of the consultation, she had noticed that he wouldn't lie flat when she wanted to change him and when she went to brush his hair, a red swelling was visible.

When he was examined, there was nothing to find apart from the red swelling in the neck, which made him cry when it was touched.

First instinct

I had not seen this before. Clearly, infection was the most likely cause, with fever and the redness of the swelling.

Differential diagnosis

People often seem to interchange cervical lymphadenopathy and lymphadenitis. But for me, lymphadenitis means there is a suppurating infection within the gland itself.

Likely diagnoses

• Infected cyst

• Lymphadenitis

The hidden clue

In this case, the clue didn't lie with this patient at all. His older sister had been in to see me a few days earlier with a rip-roaring temperature and a nasty tonsillitis. Could it be that this little boy had picked up her streptococcal infection?

Treatment

I felt it was not reasonable to guess at the likely organism causing this infection so I referred him straight away to the paediatricians. They put him on intravenous antibiotics, which helped resolve the infection. This case underlines the enormous value of continuity of family care.

Dr Mike Wyndham is a GP in Edgware, north London

What's causing the painful neck swelling on this infant?

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