Radiological Case of the Month FREE

A PREVIOUSLY healthy 5-year-old girl was referred for evaluation of "spiking" fevers (temperature to 41.1°C) that had occurred for 6 weeks. Fever aside, she was asymptomatic. There were no complaints of abdominal pain, rashes, weight loss, joint pain, or night sweats. There was no history of foreign travel.

On initial evaluation the results of the physical examination were normal except for a nontender 1×1×1-cm left axillary lymph node. The liver and spleen were not enlarged. Laboratory data included the following values: white blood cells, 8.8×10⁹/L, with 0.60 neutrophils, 0.29 lymphocytes; erythrocyte sedimentation, 84 mm/h; alkaline phosphatase, 168 U/L; alanine aminotransferase, 37 U/L; γ-glutamyltranspeptidase, 37 U/L; lactate dehydrogenase, 785 U/L. Findings were negative for heterophile antibody analysis; normal, urinalysis;negative, rheumatoid factor; negative, antinuclear antibody; negative, serology for cytomegalovirus; and normal, chest radiograph. Results of blood, urine, and throat cultures were negative for organisms.

On presentation to our hospital further testing was completed. Results of a purified protein derivative skin test were negative. Titers for human parvovirus, toxoplasmosis, and Borrelia burgdorferi were all negative. Three blood cultures obtained during fever spikes were negative for organisms. Denver panel findings (antinuclear antibody, anti–double-stranded DNA, anti–SS-A, anti–SS-B, antiscleroderma) were normal. Radioisotope bone scan findings were normal as were those from sinus radiographs. An abdominal computed tomographic scan (Figure 1, left and right) and ultrasound scans (Figure 2) were performed.