Case 3: Bilateral Facial Edema with Gingival Swelling in a 6-year-old Boy

Presentation

A previously healthy 6-year-old boy presents to the emergency department (ED) with new swelling of the left side of his face and left eyelids as well as increasing pain around the right upper molars for 7 days. He has no history of fever, loss of appetite, or change in weight.

He was hospitalized for similar complaints 3 days ago, when he developed right-sided jaw pain and facial swelling. Laboratory evaluation during hospitalization revealed a normal complete blood cell (CBC) count, basic metabolic panel (BMP), C-reactive protein (CRP), and erythrocyte sedimentation rate. Magnetic resonance imaging (MRI) of the face showed inflammatory sinus disease and a fluid collection around the right upper molar concerning for odontogenic infection. He was treated with intravenous clindamycin and experienced mild improvement of the facial swelling. He was discharged home after 48 hours with follow-up scheduled with ophthalmology, otolaryngology, and dentistry.

While at home, the swelling worsened, progressing to both sides of his face and accompanied by increasing pain, which prompted his return to the ED.

Physical examination documents a temperature of 37.1°C (98.8°F), heart rate of 89 beats/min, respiratory rate of 20 breaths/min, and blood pressure of 114/60 mm Hg. His weight is 19.9 kg (25th percentile) and height is 119 cm (50th percentile). His facial swelling now involves both sides of the jaw. A 2-cm purple gingival mass with some erythema protrudes over the right upper molar. The mass is soft, friable, and bleeds easily with manipulation. He …