Diagnostic Information

History of Present Illness Jacob is a 14-year-old male who presents to your office for evaluation of a painful swelling in the right lateral neck. His medical history is unremarkable except for a tonsillectomy at age 4. Medical History - Adverse drug effects: none

- Medications: Flonase (prn) for seasonal allergies

- Pertinent medical history: unremarkable

- Pertinent family history: paternal - alive, healthy; mother - alive, healthy

- Social history: lives on a dairy farm in west Texas; family has two dogs, three cats, four horses, and a cute hamster. Clinical Findings Extraoral examination reveals a diffuse swelling in the area of the right submandibular region. The swelling is firm but freely moveable and slightly painful to palpation. No cutaneous sinus tract was evident. The remainder of the extraoral examination and the intraoral examination were within normal limits. At the parent’s insistence, an incisional biopsy was accomplished by an otolaryngologist.

Figure 1. Swelling in the right lateral neck.

Histopathologic Findings Histopathologic examination reveals portions of a lymph node with marked cortical expansion and areas of stellate shaped necrosis surrounded by an infiltrate of histiocytes and lymphocytes (Figures 2-3). Serologic examination reveals antibodies to *Bartonella henselae*.

Figure 2. Low power image of stellate shaped necrosis with surrounding inflammatory infiltrate.

Figure 3. High power image of stellate shaped necrosis with surrounding inflammatory infiltrate.