Editor's note: Each month, this department features a discussion of an unusual diagnosis. A description and images are presented, followed by the diagnosis and an explanation of how the diagnosis was determined. As always, your comments are welcome via email at pedann@Healio.com.

We describe a previously healthy 5 year old girl who presented with acute onset of depressed mental status, new-onset seizure activity, mydriasis, bradycardia, hypothermia and respiratory depression. At the time that she started seizing, she fell and sustained minor head trauma. After stabilization in the emergency department and when the patient had returned to normal sensorium, she disclosed an ingestion of several pills forced on her by her older sister, identified to be another family member's Baclofen. In this report we describe the mechanism of Baclofen action, the risk of harm from Baclofen overdose or toxicity, and the importance of having a high index of suspicion for ingestion in cases that clinically fit the timeline for an ingestion or exposure event, even when there is initially no corroborating history.

No abstract

An 8-year-old previously healthy female presents with a 2-week history of an enlarging tender right-sided neck mass. The swelling was initially pea-sized, but over the 3 to 4 days immediately preceding her admission, the mass was noted to be enlarging. She had been seen 2 days prior to admission by her pediatrician and was prescribed sulfamethoxazole/trimethoprim, which she had been taking without improvement. In the 24 hours prior to admission she developed fever as high as 104°F, had decreased oral intake, and was complaining of neck pain. The patient had never been hospitalized before, had no known medical problems, and had no history of prior surgeries. Family history was significant for postural orthostatic tachycardia syndrome in the mother and paroxysmal atrial tachycardia in the father. The patient was in second grade, was very active, and was on the swim team. She had recently had contact with new kittens at her grandmother's home.On initial examination the patient appeared ill but nontoxic. She had a 3-cm firm mobile mass located just beneath the pinna of her right ear with associated swelling, overlying erythema, and mild tenderness with palpation located in the upper anterior cervical chain. There was no fluctuance. She had slightly decreased range of motion of her neck when turning to her right. A <0.5 cm right supraclavicular lymph note was also appreciated. The remainder of the exam was normal.