Fever, Headache, and Sore Throat in a 7-year-old Girl

Presentation

A 7-year-old previously healthy girl presents to the emergency department with 3 weeks of sore throat and a progressively worsening generalized headache. She had 1 week of low-grade fevers that resolved 1 week after the onset of these symptoms. She was evaluated by multiple medical providers, did not improve with outpatient amoxicillin for presumed streptococcal pharyngitis, and had a reportedly normal neck computed tomography (CT) scan at an outside facility. Three days before presentation, she developed nonbloody, nonbilious emesis and worsening headaches. She presents to the emergency department with concern for dehydration due to inability to tolerate oral intake.

Her medical history is significant for premature twin birth at 35 weeks’ gestation. The family says there are no home medications, allergies, significant family history, or sick contacts.

On examination, she is afebrile but slightly tachycardic, pale, and tired with bilateral eyelid edema. The left tonsil occupies approximately 75% of the left oropharynx; exudate is absent. She has shotty left submandibular adenopathy. The remainder of the physical examination is unremarkable.

Laboratory evaluation shows a mild leukocytosis (15.1 × 10³/μL), normocytic anemia (11.9 g/dL), thrombocytopenia (142 × 10³/μL), and 18% immature neutrophils. A comprehensive metabolic panel is normal. A heterophile antibody test is negative. A CT scan of the head without contrast shows pan-paranasal sinus disease and enlargement of the left palatine tonsil, though only partially visualized.

She is admitted with a diagnosis of dehydration secondary to sinusitis. On rounds the following morning, her left tonsil is noted to occupy the entire left oropharynx and touches the uvula, and her left neck appears full. She has no …