Strep throat, torticollis in 8-year-old girl
An 8-year-old girl presents to your outpatient clinic with a 2-day history of sore throat, fever, and neck pain. Your medical assistant tells you that the child had an upper respiratory tract infection about 2 weeks before but had recovered completely and uneventfully about a week ago. There was no known exposure to persons with a similar illness and no recent travel.
Analgesics and fluids at home had helped with her symptoms. There was no significant cough or rhinorrhea. The mother suspects an infection from streptococcus because of the abrupt onset and severity of her daughter's sore throat.
You review the child's medical record outside of the examination room. Her parents are friends of yours, and you know the child well. You know that when the child presents to the office with an acute illness, it's usually more than something minor, like a cold or gastrointestinal infection that can be handled at home. The child's past medical history is unremarkable, without previous hospitalizations or chronic health conditions. At her last well exam 4 months ago, you noted that immunizations were up to date, including the completed series for pertussis, Haemophilus influenzae type b (Hib), and Streptococcus pneumoniae. Physical examination then was normal, with no evidence of scoliosis or musculoskeletal anomalies. The growth chart revealed both linear and ponderal growth rate to be normal and corresponding to familial patterns. A previous allergic reaction (urticaria) to cefdinir is noted.
In the office, vital signs include a temperature of 38.4° C; heart rate (HR) of 112 beats per minute; and respiratory rate (RR) of 28 breaths per minute. Blood pressure (BP) is normal.
On entering the examination room, you see the girl lying on her right side, and she has difficulty generating a smile in response to your greeting. She is uncomfortable and says both her throat and neck hurt. She is cooperative, but only reluctantly turns her head, preferring to lie down so her head is supported. She does not recall sleeping in an unusual fashion, no extra pillows and so on, and does not recall any injury at school or at home with her younger brother. She is anxious and reluctant to be examined and, being a bright little girl, has already anticipated that a throat swab is only going to make matters worse for her today. She had received a throat swab before when a streptococcal pharyngitis had been suspected. You can't recall any recent strep throat or ear infections, and a quick scan of her chart confirms this.
You get the history from the mother. She confirms that her daughter had a rather typical cold several weeks ago but that all her symptoms had resolved. In fact, she was fine until just a few days before. She then developed a gradually increasing sore throat and low-grade fever. The neck pain began just this morning, and she was reluctant to get out of bed. The mother reported no vomiting, lethargy, headache, or respiratory symptoms; nothing different regarding activities; no trauma; and no past neck stiffness or pain.
The physical exam
You proceed to the physical examination. You see that the child is well hydrated and breathing easily. Examination of head and scalp are normal. The eye examination is normal as well, without injection, discharge, or edema. Next, you move to the mouth and note moist mucous membranes, a normal-appearing tongue, and no lesions on lips, gums, or buccal mucosa. Pharyngeal erythema is present along with 3+ symmetric tonsillar size and palatal petechiae. You see the uvula is red and in a midline and neutral position. Although somewhat difficult to visualize as the child grimaces to open her mouth wider, the posterior pharyngeal wall is smooth, symmetric, and without a cobblestone appearance. Notably absent are tonsillar exudate, drooling, and trismus. Teeth appear healthy. Tympanic membranes are translucent, gray, and mobile, and the nasal exam is normal without discharge or congestion.
The neck exam reveals palpable, mobile, nontender anterior cervical lymph nodes that you estimate to be about 1.5 cm to 2 cm in size. They extend down the anterior cervical chain and appear equal in size and extent on both the left and right. Your exam of the right side of the neck is somewhat limited this time, however, because of the child's preference to look to the right. Torticollis is present, and although you can coax her to turn her head both left and right almost fully, she manages to do it only slowly. Fearful of pain, she resists your assistance and is relieved to lie back down as you proceed with the examination. Again, she finds it most comfortable when her head is facing to the right. The remainder of the examination is normal, including clear lungs, no abdominal pain or hepatosplenomegaly, and no rash. Both Kernig and Brudzinski signs are negative.
As she correctly anticipated, you perform the throat swab, and the rapid antigen test for strep is positive. Your clinical impression is correct—with the tonsillitis, uvulitis, and petechiae, this looks like classic strep throat—and you are confident that once treatment begins you can return your patient to good health. Before you send her home, you administer an oral dose of 10 mg/kg of ibuprofen, and you keep her in the office for about an hour. You reevaluate her to confirm negative meningeal signs, better neck movement, and a decrease in throat pain. She still needs coaxing to turn her head, but she clearly is feeling better. You suspect that the torticollis is from the cervical adenopathy. The exam is reassuring, and you discharge her home on a regimen of oral antibiotics, analgesics, and fluids. Arrangements are made for telephone follow-up the next morning. You expect to see dramatic improvement as the antibiotic regimen begins. Something intangible here, however, makes that morning call more anticipated than usual.
Later that night, the child begins vomiting, and the neck pain and stiffness increase, prompting a needed reevaluation. Earlier, after discharge from your clinic, she did take and tolerate the prescribed first dose of amoxicillin/clavulanic acid at 90 mg/kg divided into 2 doses per day. She had been fine with this antibiotic combination in the past in spite of the reaction to cefdinir noted previously. Concern regarding increasing reports of in vivo failure because of pharyngeal copathogens and her more worrisome presentation prompted your choice of the broader spectrum antibiotic.
It has been about 10 hours since your initial evaluation, and these additional and worsening symptoms require immediate attention. The child is taken to the emergency department. Now she has an elevated temperature of 38.3°C, and her neck pain and torticollis have become worse. She will not turn her head to the left when requested, and passive neck movement is resisted vigorously. She still complains of sore throat, and fluid intake has decreased. Examination reveals similar findings as earlier described, including the pharyngeal signs. Again, a midline but erythematous uvula is seen. There is no evidence of strider or respiratory distress. She lacks drooling and trismus. Meningeal signs also are negative.