Abstract | November 18, 2023
A Neck Mass Deviating from the Norm
Learning Objectives
- This case demonstrates the importance of maintaining a wide differential for a young adult presenting with a painful neck mass. Cervicofacial actinomyosis is a suppurative and granulomatous disease that exists as a commensal organism in humans but becomes invasive when it penetrates the subcutaneous tissue2. Definitive diagnosis is made with surgical biopsy due to non-specific findings on imaging techniques. Prolonged antibiotic therapy is typically required for treatment.
Introduction
Cervical lymphadenopathy is common in children with up to 45% of otherwise normal children having palpable lymph nodes1. However, when coupled with a neck mass additional diagnoses should be considered including: viral, bacterial, protozoal, fungal and malignancies as potential causes.
Case Presentation
An 18-year-old male presented with a 2-week history of right-sided neck pain and swelling. He endorsed drenching night sweats but denied any recent trauma, dental work, travel, contact with domestic or farm animals, or sexual activity. Labs were notable for WBC 32.6, ESR 74, CRP 159. HIV, EBV, CMV, Bartonella antibodies were negative and histoplasmosis antigen was collected. On exam, there was a large fluctuant mass along the right side of his neck along with multiple enlarged lymph nodes. CT scan revealed a 14×4.1×5.0 cm peripherally enhancing, septated fluid collection within the retropharyngeal space causing severe mass effect on the vasculature and airway. Vancomycin and ampicillin/sulbactam were started for presumed bacterial abscess and Otolaryngology was consulted.
Otolaryngology performed an emergent incision and drainage, and antibiotics were narrowed to clindamycin. Due to reaccumulation of fluid, antibiotics were broadened to ceftriaxone, vancomycin, and metronidazole, and he underwent lymph node biopsy with repeat drainage. Lymph node biopsy showed hyperplasia without concern for other pathology. Transoral wound culture grew coagulase rare negative staphylococcus, rare streptococcus viridans, actinomyces, and fusobacterium nucleatum. Histoplasmosis antibody returned positive.
Final Diagnosis
Polymicrobial bacterial infection, actinomycosis
Outcome/Follow-Up
Patient was started on intraconazole and he was discharged home with a 6-week course of amoxicillin-clavulanate and itraconazole. On follow up, repeat histoplasmosis Ag and Ab tests were negative. Given the negative tests, it was assumed that either the initial test was a false positive or the initial infection had resolved with treatment and no significant antibody response.
References and Resources
- Leung, A. K., & Davies, H. D. (2009). Cervical lymphadenitis: etiology, diagnosis, and management. Current infectious disease reports, 11, 183-189.
- Moturi, K., & Kaila, V. (2018). Cervicofacial actinomycosis and its management. Annals of maxillofacial surgery, 8(2), 361.
