What can cause an erythematous, fluctuant, nontender mass in the middle of the neck?
Full Case Study: (Its the last of 6 cases and I just can't figure this one out, because of all the possibilities, there is always something that doesn't line up.)
The 26-year-old man presented for evaluation of a neck mass and a right axillary mass. The patient, who came to the United States from Vietnam 6 1/2 years ago, noted midline neck mass. The mass gradually increased in size. Approximately 3 weeks prior to admission, he noted a midline neck mass. These masses were incised and drained twice. Samples of purulent material were sent for routine bacterial culture at an outside hospital. The patient had lost 3 kg (ca. 7 lbs) in the 2 months prior to admission but denied fever. Travel history was notable for his having lived in Arizona for 6 years prior to moving to Boston.
On examination, he was afebrile. An erythematous , fluctuant, nontender mass (8cm x 6cm) was present in the midline of the neck. (Fig. 5.1) (computed tomogram[CT] scan in fig. 5.2).The right axilla demonstrated incision sites that were draining and were tender to palpation. He had no adenopathy elsewhere. His (PPD) purified protein derivative skin test was reactive, and his chest x-ray was notable for apical scarring in the right lung.
Because of the positive PPD and apical scarring seen on the patient's chest x-ray, the clinical suspicion of cervical ________ was high, and the patient was begun on a four drug anti- _________________ regimen.
Several days after the neck mass was drained of several milliliters of purulent material for culture, a mold was found to grow on the blood agar plates in the routine bacteriology section of the microbiology laboratory. The mold was white (Fig. 5.3) and initially did not have any identifying characteristics when a lactophenol cotton blue preparation was examined under a phase-contrast microscope. It was subcultured at both room temperature and body temperature, and after subculture began to demonstrate the presence of spores microscopically (Fig. 5.4) The identification was confirmed by using a commercially available genetic probe.