Case 3: Anisocoria in a 5-year old Girl

William McEachern; Alice Walz; Keerti Dantuluri; Daniel Dulek; Kristina Betters

doi:10.1542/pir.2018-0132

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William McEachern, MD*
Alice Walz, MD^†
Keerti Dantuluri, MD^‡
Daniel Dulek, MD^‡
Kristina Betters, MD^†

^*Department of Pediatrics,
^†Division of Pediatric Critical Care Medicine, and
^‡Division of Pediatric Infectious Diseases, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN

AUTHOR DISCLOSURE
Drs McEachern, Walz, Dantuluri, Dulek, and Betters have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Presentation

A previously healthy 5-year-old girl presents to the emergency department with a chief complaint of persistent left-sided neck swelling with new-onset headache, odynophagia, and pupillary asymmetry. She has developed the left neck swelling over the course of the past month. She is initially evaluated with lateral neck ultrasonography as an outpatient; this demonstrates enlarged cervical lymph nodes without fluid collection or abscess. She completes a course of clindamycin for presumed cervical lymphadenitis and is subsequently treated with a course of amoxicillin–clavulanic acid after the first course of antibiotic agents fails to improve her symptoms. Parents state that they have not appreciated a significant change in the degree of neck swelling after the 2 antibiotic drug therapy courses, and the girl endorses a major increase in neck pain and headache last night that is unresponsive to acetaminophen or ibuprofen, both of which had previously been alleviating her pain. She is also noted to have pupillary asymmetry for the previous 2 days.

She has not had fevers, vomiting, seizures, weight loss, or changes in speech or vision. She remains at her neurologic baseline. There is no history of trauma or recent surgery. She is fully immunized and has no known allergies.

In the emergency department she is well-appearing, afebrile, and with age-appropriate vital signs. She is noted to have partial left-sided ptosis and miosis, as well as tender, palpable left-sided cervical lymphadenopathy (Fig 1).

Figure 1.

Left-sided ptosis and miosis.