What Is Causing an Infant’s Facial Swelling?

Authors:
Geoffrey Lowe, MD; Courtney Ochoa, MD, MS; Amee Patel, MD, MPH; and Jo-Ann Nesiama, MD, MS
University of Texas Southwestern Medical Center, Dallas, Texas

Citation:
Lowe G, Ochoa C, Patel A, Nesiama J-A. What is causing an infant’s facial swelling? Consultant. 2019;59(12):365-366, 370.

A healthy 55-day-old full-term infant presented to the emergency department (ED) with a 4-day history of left-sided facial swelling with increasing firmness (Figure 1).

The parents initially had been concerned about a possible allergic reaction to the infant’s formula and had switched him to goat’s milk without improvement. The patient then had been seen by his pediatrician, who recommended evaluation in the ED. The parents denied fever, upper respiratory tract symptoms, decreased oral intake, or difficulty breathing in the child.

Figure 1. A 55-day-old infant presented with a 4-day history of left-sided facial swelling with increasing firmness.

In the ED, ultrasonography of the neck was ordered, the results of which demonstrated an asymmetric enlargement of the left masseter muscle (Figure 2).

Figure 2. Ultrasonography demonstrated an asymmetric enlargement of the left masseter muscle.

While in the ED, the patient had a temperature of 38.0°C. A full sepsis workup was initiated with blood, urine, and cerebrospinal fluid (CSF) cultures, and the patient was started on empiric ceftriaxone.

Results of a complete blood cell count were significant for leukocytosis, with 23,500 white blood cells/µL with 37% neutrophils, 45% lymphocytes, and 14.8% monocytes. The C-reactive protein (CRP) level was elevated at 3.94 mg/L, and the erythrocyte sedimentation rate (ESR) was elevated at 89 mm/h. Results of a comprehensive metabolic panel, CSF indexes, and urinalysis were unremarkable. The patient was treated with empiric ceftriaxone, and an otorhinolaryngologist was consulted, who recommended magnetic resonance imaging (MRI) for further evaluation (Figure 3).

Figure 3. MRI scans of the head and neck.