Case by Nicholas Dimenstein MD, CNH PEM Fellow

An 11-year-old male was brought into the ED by his parents with concerns that another player may have stepped on his neck during football practice. His neck is slightly swollen. He complains of a minor headache that started on the drive to the ED. Denies neck pain, decreased ROM, nausea, vomiting, LOC, or vision changes. The patient was wearing a helmet and shoulder pads.  

PMHx: concussion 3 years prior. No surgical history, no meds, NKDA, IUTD.

Vitals: HR 101, RR 24, BP 129/88, 99%O2 on RA, weight: 76kg

General:  Alert.  appropriate for age.  cooperative. Obese-appearing child.
Skin:  Warm.  dry.  intact.  no pallor.  
HEENT: NC/AT, TM clear b/l. Oropharynx clear, MMM, PERRLA, EOMI. No battle-sign or bruising
Neck:  firm, non-tender mass present on the right lateral/posterior aspect of the neck, approximately 7-8 cm in length. Non-fluctuant. Non-pulsatile.
CV: RRR, normal s1 and s2, no murmurs
GI: Protuberant abdomen. Soft.  Nontender.  No HSM.
MSK: Normal ROM.  normal strength.  no tenderness.  no swelling.  no deformity.
Neuro: Alert and oriented. CN2-12 intact. Normal gait, balance, speech, developmentally appropriate.  
Psychiatric:  Cooperative.  appropriate mood & affect. 

Images were obtained, including an XR neck and ultrasound:

XR neck: No signs of fractures

US Neck: Extensive hyperemic lymphadenopathy of the right neck with loss of normal lymph node architecture. Differential considerations include includes neoplasm such as lymphoma; reactive lymph nodes/lymphadenitis is possible given imaging findings, though the absence of tenderness on exam is not typical. Consider tissue correlation.

After the Radiologist calls you with the results, you nervously go get more history. No fevers, weight loss, chills, night sweats, sick contacts, TB exposures, cat exposures, or recent travel. On second thought, Dad says perhaps his neck has actually been slightly swollen for a few weeks but is not certain.

Labs: WBC 12.99, Hgb 13.2, platelets 385. ESR: 14, CRP 0.56, Coags, BMP, wnl. Uric acid 5.5, LDH 382. heterophile: negative. CXR unremarkable.

Obtained CT neck and chest which showed…