Author: Krishna Khanal, MD
Co Author #1: Sandhya Basyal, MBBS
Co Author #2: James Daniels, MD MPH
Co Author #3: Merle Muller, MD

History:
A 20 year old previously healthy Caucasian collegiate football player presented to the training room with a two week history of right neck swelling and pain. He reported some difficulty in swallowing, cough productive of greenish sputum, and shortness of the breath. A few weeks prior to the training room visit, he was evaluated and treated empirically for sore throat and bronchitis with oral azithromycin and doxycycline, respectively. However, he was still symptomatic. One week prior to presentation, he was re-evaluated for the neck pain and presumed "stinger" injury at his primary care physician's office. He underwent a CT of the cervical spine, which was unremarkable. He denied any history of contacts with visibly-ill people or animals, recent travel, or risk factors for HIV and hepatitis. He reported weight loss of 19 pounds over the course of 8 months.

Physical Exam:
He appeared toxic and was in moderate distress with no icterus. Vital signs included temperature of 99.9 degrees Fahrenheit, HR 80 beats/min, BP 144/68 mm Hg, RR 20 breaths/min, and pulse oxymetry of 94% on room air. Oral examination showed erythema and swelling of the posterior pharyngeal mucosa and tonsils without exudates. The neck was tender to palpation on the right side with a palpable soft to firm mobile mass in the submandibular area. On auscultation of the lungs, there were diminished breath sounds of lung bases more on the right with no crackles. His cardiac exam normal. The abdominal exam was negative for tenderness and hepatosplenomegaly. Examination of the skin showed no rashes or petechiae. Neurologic examination was normal.

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