Case 3: Sore Throat and Fever in a 4-year-old Boy.

A 4-year-old previously healthy and fully immunized boy presents with a 2-day history of sore throat and a 1-day history of fever and drooling. He awakened today with worsening sore throat, drooling, and subjective fever. He complains of pain during swallowing and refuses oral intake. He has no cough, congestion, sick contacts, or recent travel. His prenatal, natal, and postnatal histories contain no significant information. His immunizations are up to date. At initial presentation, his temperature is 39.6°C (103.4°F), heart rate is 160 beats per minute, respiratory rate is 22 breaths per minute, and oxygen saturation is 95% in room air. Physical examination reveals an alert and interactive boy who is drooling and appears uncomfortable. He is in the tripod position and has a muffled voice but no stridor, nasal flaring, or labored breathing. His chest is clear to auscultation bilaterally. His neck is supple and has no swelling, erythema, or tenderness. His throat is not examined. Findings on the remainder of the physical examination are unremarkable. Results of laboratory evaluation include: • White blood cell count 30,900/mL (30.9 109/mL), with 66% segmented neutrophils, 22% banded neutrophils, 5% lymphocytes, and 7% monocytes • Hemoglobin 13.9 g/dL (139 g/L) • Hematocrit 39.1% (0.39) • Platelet count 473 103/mL (473 109/L) • Erythrocyte sedimentation rate, 8 mm/h • C-reactive protein, 3.2 mg/L (30.5 nmol/L) Blood is drawn for culture. Neck soft-tissue radiography leads to the diagnosis.