9-year-old Boy with Unresolving Pharyngitis

Grace Truong; Hanna Huh

doi:10.1542/pir.2019-0105

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Grace Truong, MD*,^†,^‡,^§
Hanna Huh, MD*,^†

^*McGovern Medical School, Houston, TX
^†Children’s Memorial Hermann Hospital, Houston, TX
^‡Baylor College of Medicine, Houston, TX
^§Texas Children's Hospital, Houston, TX

Address correspondence to Grace Truong, BS, McGovern Medical School, 6341 Fannin St, Houston, TX 77030. E-mail: grace.truong{at}uth.tmc.edu

AUTHOR DISCLOSURE
Ms Truong and Dr Huh 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 9-year-old previously healthy Hispanic boy presented to the emergency department (ED) with severe throat pain and difficulty breathing. His symptoms began 5 days before admission and was accompanied by a one-time fever of 103°F (39.4°C) that resolved with acetaminophen. In clinic 1 day before admission, he was negative on rapid strep test but still given penicillin (based off clinical suspicion for strep pharyngitis) and ibuprofen for 1 day without improvement. After progressively worsening throat pain, odynophagia, vomiting, and poor oral intake, he was taken to the ED.

In the ED, the patient was afebrile, pulse was 102 beats/min, respiration rate was 18 breaths/min, blood pressure was 106/73 mm Hg, and oxygen saturation was 100% on room air. The patient was in mild distress with shortness of breath and chest pain. He denied headaches, cough, wheezes, palpitations, or rashes. There was no history of sick contacts, recent travel, or exposure to wild animals. Immunizations were up to date. Physical examination was significant for drooling, an erythematous posterior pharyngeal wall and palatoglossal arch with white exudates, and 3+ tonsils bilaterally. He also had right anterior cervical and mandibular lymphadenopathy with the largest node measuring 2 cm. Laboratory evaluation showed a leukocytosis of 28.9 × 10³/mcL with 78% neutrophilic predominance and transaminitis with alanine transaminase of 252 U/L and aspartate transaminase of 343 U/L. Neck soft tissue computed tomography scan showed mucosal thickening of the right epiglottis, aryepiglottic fold, and oropharyngeal wall, but no enhancements suggestive of abscess formation.

The patient was admitted for evaluation of severe pharyngitis and management of dehydration. He continued to have severe odynophagia and …