A 5-year-old Latin American girl was seen in the Children’s National Medical Center Emergency Room for evaluation of severe jaw pain. She had been in good health until 3 to 4 days before admission, when she developed a sore throat that was treated with common cold medication. Her throat had been sore for 2 days when she developed a fever of 38.9°C and swelling over the right side of her face. During the next 48 h fever continued and the swelling and pain became significantly worse. On the morning of admission she went to her local hospital where a rapid antigen test for group A Streptococcus was negative; she was sent home with a prescription for amoxicillin-clavulanate. She received one dose of this medication. Later that day her temperature rose to 40.0°C and she was subsequently brought to the admitting hospital. On admission she complained of significant pain on chewing, which had limited her ability to take food by mouth. She had increased snoring over the previous few days, without drooling or stridor. She had no history of trauma to the face or jaw and had no prior dental treatment or dental complaint. Both parents had had a sore throat 1 week before her admission, which resolved spontaneously in 2 to 3 days. Her past medical history was unremarkable.
Physical examination demonstrated a sleepy but easily arousable child in no apparent distress who was well-nourished and hydrated. Temperature was 39.4°C, pulse 150 beats/min, respiratory rate 24 breaths/min and blood pressure 83/47 mm Hg. Head and neck examination revealed an erythematous, warm, nonfluctuant and extremely tender swelling in the upper right preauricular region of her face. The pain became worse on attempting to open her mouth. She had decreased ability to open her jaw, with left-sided deviation on maximal opening. Her right eyelid was swollen, without erythema or tenderness. She had intact extraocular eye movements. The right external ear canal had mild erythema, but tympanic membranes were clear and mobile bilaterally. Her throat showed no erythema or exudate, and her uvula was midline. Teeth and gums were in good condition with no obvious oral pathology. She had a few palpable anterior cervical lymph nodes, right greater than left, the largest node measuring 0.5 by 0.5 cm. The neck had decreased range of motion; she tilted her neck to the left as a position of comfort. The remainder of the physical examination was normal.
Leukocyte count was 14 600/mm 3 with 76% segmented neutrophils, 8% band forms, 14% monocytes and 2% lymphocytes. Hemoglobin was 11.3 g/dl. Hematocrit was 33.4% and platelet count was 396 000/mm 3. A blood culture was negative. She was treated with cefotaxime and clindamycin. A diagnostic test was performed which revealed the etiology of her illness.
We thank Dr. Nalini Singh-Naz for involvement in the management of this case and Dr. William Rodriguez for critical review of the manuscript.