JAMA Clinical Challenge | Clinician's Corner

Neck Mass in a Returning Traveler

Amanda Christini, MD; Emmanuel King, MD
JAMA. 2012;308(20):2142-2143. doi:10.1001/jama.2012.33634.
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A 49-year-old man with a history of diabetes presents to the emergency department of a US hospital with an abdominal wall abscess. He recently completed a summer pilgrimage to Bangladesh and Saudi Arabia. Incision and drainage are performed but no cultures are sent. He is given empirical double-strength trimethoprim-sulfamethoxazole twice daily for 14 days. Several weeks later he returns with painful swelling of the left side of his neck associated with subjective fever and chills. On examination he is afebrile and a tender, 2-cm fluctuant neck mass is palpated. A contrast computed tomography (CT) scan of the neck is performed (Figure 1). The patient is given oral clindamycin with plans for ultrasound-guided incision and drainage by an otorhinolaryngologist. However, after 8 days of empirical clindamycin, he returns to the emergency department with worsening neck pain. He is afebrile and no laboratory abnormalities are noted except for an elevated glucose level of 335 mg/dL.

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Figure 1. Contrast computed tomography scan of the neck revealing a ring-enhancing mass with central hypodensity in the left sternocleidomastoid muscle associated with fat stranding and irregular margins.
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Figure 2.Burkholderia pseudomallei from this patient growing on tryptic soy sheep's blood agar showing characteristic wrinkled colonies. Image provided with permission by Paul Edelstein, Clinical Microbiology Laboratory, Hospital of the University of Pennsylvania.
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