Right facial swelling and fever.

by J. Alan Morgan, D.O., FACEP

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Chief Complaint: Right facial swelling and fever.

History of present illness:

A 40 year-old black male presents to the emergency department with a 24 hour history of right facial swelling and fever. The patient initially noticed a small area of erythema developing on his right check that progressively became painful, hot, tense, and swollen. This lesion extends to include the entire cheek, upper lip, and eyelids. Associated symptoms include rigors, malaise, and cephalgia. He denies any trauma to the area such as insect bites or abrasions. Past medical history includes alcoholism and intravenous heroin abuse and is currently undergoing methadone therapy.

Physical Examination:

The patient is an alert male who appears to be in moderate discomfort with a fiery red well demarcated swollen area located on the right cheek. Vital signs include temperature 40.1 oC (orally), pulse 110 beats/minute, blood pressure 144/96 torr, and respiratory rate 26 breaths/minute. The border of the raised erythematous facial swelling though irregular, is sharply demarcated from the adjacent skin and extends from the tragus to the right paranasal area. It extends superiorly to the right periorbital region and inferiorly to the right commissure of the mouth. The lesion is exquisitely tender and hot on palpation. (Fig 1) There is no evidence of disruption of the skin barrier. Visual acuity is normal. The sclera are clear and there is full range of ocular movement. Oral examination does not reveal periodontal disease caries, or tooth pain. Upper extremity examination reveals needle tract markings. No murmur, petechiae, splinter hemorrhages, Osler's nodes, Roth spots, Janeway lesions, or splenomegaly are noted. The remaining physical examination is normal.

Laboratory:

The white blood cell count is 8,700 and the erythrocyte sedimentation rate is normal. Sinus radiographs show no evidence of pathology. Blood cultures, HIV-1, and HIV-2 were obtained. The urinalysis shows 5-7 red blood cells/HPF, 0 white blood cells/HPF, and negative protein. An EKG shows sinus tachycardia. Two-dimensional echocardiography does not detect valvular vegetations.

The patient course, diagnosis and discussion

From Academic Emergency Medicine 2(3):231, 234-237 1995 March

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