History of Present Illness: 18 year old female presents with a worsening neck mass over the last few weeks. 

• Three weeks weeks ago, she reports initially having fevers, aches, chills and severe sore throat.
• One week ago, she was seen in the clinic for sore throat and neck swelling and had a Monospot test which was negative
• Diagnosed with probable viral syndrome and was placed on a Medrol dose pack for the neck swelling. 
• After some initial improvement, the pain, swelling and redness worsened, prompting her visit to the ED
• Review of systems: She denies any fever, chills. Other than above history, she did report a rash for 2-3days about 3 weeks ago. She didn’t notice any shortness of breath or cough until day of ED visit. She did recent dental work, no TB exposure

Past Medical History:

1. Seizure disorder – partial seizures, seizure free for last 2 years
2. Urinary tract infection 2 months ago with admission for IV/Abx
3. No Previous History of Mononucleosis

Meds: 

1. Lamictal 100mg BID
2. Prednisone taper

Social: No ETOH, No Smoking, College Freshman

Physical Examination:

• Vital Signs: Temperature 97.7, pulse 54, Respiratory 18, Pox 88%, 105/68
• Gen:  A/O, nontoxic appearing
• HEENT:  No thrush, No dental 
• Neck:  Significant fullness Left Neck with mild erythema, some fluctuance.  Mild lymphadenopathy below mass in L. ant cervical chain.
• Chest: L clear, HS1S2
• Abdomen: No splenomegaly
• Ext: Benign.

Laboratory Evaluation:

• WBC: 18.44 Segs 75, Lymphs 19
• H/H: 10.6/31.9 Platelet 360
• BMP normal

Radiology:

Questions:

1. What was/were the most likely risk factor(s) for the evolution of this process
   1. The use of the steroid taper
   2. Underlying viral syndrome per history
   3. Her Lamictal led to an immunocompromised state
2. What studies are missing in the work-up (hint: look at vital signs)?
3. Why may she not have had a fever?
4. What is the likely diagnosis (Gram stain below) and the organism associated with it?

Feel free to leave a comment of any or all of the answers.

Answer is provided in the link below:

https://yourhealthforumbydrcirino.org/2019/08/31/18-year-old-with-increasing-neck-mass/