Patient Presentation A 2-year-old female came to clinic with sudden onset of left-sided neck swelling. She had been well the previous evening and woke up with the swelling. She had no pain, fever, skin rashes, mental status changes, night sweats or weight loss. She was eating and breathing normally. She did have some rhinorrhea for the past 3 days. Her mother said that the swelling had not seemed reddened or warm to her. The past medical history showed a healthy female with 2 previous ear infections and she was up to date on her immunizations including having one Measles-Mumps-Rubella vaccine. The family history revealed stroke and renal abnormalities. The review of systems was normal. The pertinent physical exam showed temperature of 36.2° C, pulse = 108 beats/minute and respiratory rate = 32 breaths/minute. Growth parameters were in the 10-75% with no weight loss and she was not distressed. HEENT showed normal ears and throat. She had obvious left submandibular, subauricular, and anterior auricular swelling that covered the angle of the mandible. The swelling was confluent, firm but not hard, non-tender, non-erythematous and not warm. She had full range of motion in the temporomandibular joint and neck. There was no fluid seen from the salivary ducts when they were milked. There was no pain or swelling of the dental tissues. There were shoddy anterior and posterior cervical lymph nodes. There were no supraclavicular nodes palpable. Skin was normal with no rashes and no dimpling notable on the neck. There was no thyroid enlargement. Lung examination was negative. The diagnosis of parotitis/sialadenitis was made. Because she was immunized and there were several enteroviruses in the community, one of these viruses was suspected as the cause. The laboratory evaluation included mumps titres which eventually were negative. The patient's clinical course showed she had a low grade fever and developed a rash on her palms and soles later the first day, but she had slow resolution of all symptoms over 7 days. Discussion Sialadenitis is swelling of the salivary glands, which may include the parotid gland. If the parotid gland is involved then it is called parotitis. Parotitis can be caused by: Infections Viruses - primary mumps but also cytomegalovirus, coxsackievirus and other enteroviruses, lymphocytic choriomeningitis virus, human immunodeficiency virus, influenza A, and parainfluenza virus 1 and 3 Mycobacterium, non-tuberculous Staphylococcus aureus Drug reaction - iodides, phenylbutazone, thiouracil Metabolic disorders - diabetes, cirrhosis, malnutrition Pneumoparotitis - i.e. air is forced into the salivary ductal system, e.g. instrument playing, ventilation during anesthesia Psychiatric - bulemia, pica Salivary duct calculi - i.e. sialolithiasis Starch ingestion Mumps belongs to the Paramyxoviridae family of RNA viruses. It is spread by respiratory secretions and humans are the only known natural host. Because of vaccination there are < 300 cases/year in the U.S. with most being in people > 14 years of age. In immunized children, mumps is not a common cause of parotitis. Incubation is from 16-18 days but cases may occur from 12-25 days after exposure. Maximum communicability is from 1-2 days before parotid swelling to 5 day after onset. About 1/3 of infections do not have clinically apparent salivary gland swelling but only have respiratory symptoms. Learning Point The differential diagnosis of a neck mass includes: Infectious lymphadenitis - most common cause of a neck mass. Some agents include: Viral Adenovirus Coxsackie Epstein Barr virus Influenza Parainfluenza Other respiratory viruses Bacterial Staphlococcus aureus Streptococcus, group A beta-hemolytic Bartonella henselae Haemophilus influenzae Anaerobic bacteria if dental infection is suspected Toxoplasmosis - if single lymph nodes Fungal Actinomycosis Histoplasmosis Tuberculous Mycobacterium tuberculi Atypical mycobacterium Unknown Kawasaki disease Noninfectious inflammatory masses Sarcoid Sialadenitis Congenital Branchial anomalies - lie along the anterior border of the sternocleidomastoid muscle or deep to it, occurring anywhere between the external auditory canal and the clavicle. There can be cysts, sinuses or fistulas. Remember branchial clefts are external (mainly ectodermal) and branchial pouches are internal (mainly endodermal) in location. First branchial cleft abnormalities - found superior to the hyoid bone First cleft and pouch forms ear Second branchial cleft abnormalities - 2/3 of the way down the sternocleidomastoid muscle - most common branchial cleft abnormality Second, third, and fourth clefts are obliterated Second pouch forms tonsil Third branchial cleft abnormalities - 2/3 of the way down the sternocleidomastoid muscle Third pouch forms the parathyroid gland and thymus Fourth branchial cleft abnormalities - are not seen Fourth pouch forms parathyroid gland Dermoid cysts Encephalocoeles Laryngocoeles Parathyroid cysts Thyroglossal duct cysts, sinuses and fistulas Thymic cysts Vascular lesions Hemangiomas Hemangiolymphangiomas Lymphangiomas including cystic hygromas Tumor Benign - teratoma, desmoid tumor, myositis ossificans, shortening of the sternocleidomastoid muscle Malignant - histiocytosis, lymphoma, neuroblastoma, schwannomas, rhabdomyosarcoma Questions for Further Discussion 1. Categorize neck masses by location, i.e. lateral, anterior, posterior? 2. When should lymphadenopathy be evaluated? 3. What types of imaging modalities are available to evaluate neck masses and what are their indications? Related Cases Disease Parotitis Neck Disorders and Injuries Salivary Gland Disorders Symptom/Presentation Facial Swelling Neck Mass Specialty Infectious Diseases Otolaryngology Age Toddler To Learn More To view pediatric review articles on this topic from the past year check PubMed. Information prescriptions for patients can be found at MedlinePlus for this topic: Neck Injuries and Disorders and Salivary Gland Disorders. To view current news articles on this topic check Google News. To view images related to this topic check Google Images. Sadler TW, Langman's Medical Embryology. Williams and Wilkins, Baltimore, MD. 5th edit. 1985;281-294. American Academy of Pediatrics. Mumps, In Pickering LD, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2006;464-468. Rudolph CD, et.al. Rudolph's Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1279-1281. ACGME Competencies Highlighted by Case Patient Care 1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors. 2. Essential and accurate information about the patients' is gathered. 3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made. 4. Patient management plans are developed and carried out. Medical Knowledge 10. An investigatory and analytic thinking approach to the clinical situation is demonstrated. 11. Basic and clinically supportive sciences appropriate to their discipline are known and applied. Practice Based Learning and Improvement 13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used. Author Donna M. D'Alessandro, MD Professor of Pediatrics, University of Iowa Children's Hospital Date October 8, 2007 (Source: PediatricEducation.org)

Patient Presentation A 5-year-old male came to clinic for a second opinion of fever referred by his local physician. Eight weeks previous he had a fever to 40° C and exudative pharyngitis treated with penicillin which was stopped after 2 days because the culture was negative. The fever continued off and on for the next two weeks up to 39.5° C. Laboratory testing at that time was negative including a complete blood count, differential and monospot. He was then improved until about 4 weeks previous when he had flu-like symptoms, sore throat, lethargy, and fever to 39° C for 24 hours. He was diagnosed with sinusits and was placed on amoxicillin for 10 days. He was again improved until 3 weeks ago when he complained of mild right leg pain. Three days later he became febrile and he had a mild limp. He was seen by his local physician again who was concerned about septic arthritis. Erythrocyte sedimentation rate was 75 mm/hour and the hip ultrasound found a small effusion but no aspiration was done or antibiotics given. A bone scan the following day was negative. Since that time the leg pain had ceased and he had two fevers to 38.1° C. The past medical history revealed a healthy child. The family history was positive for heart disease, thyroid disease, and pyloric stenosis. The social history revealed traveling to Florida before the first fever. The patient is in childcare where there is a rabbit. Ther is no water exposure. The review of systems was negative including no joint pain, muscle pain, rashes, weight changes, gastrointestinal or genitourinary complaints. The pertinent physical exam showed a smiling boy with growth parameters in the 50%. The examination was negative except for bilaterally small axillary nodes and shoddy groin nodes. He had full range of motion in all joints and no pain. The diagnosis of fever most likely secondary to multiple viral infections (possibly Epstein-Barr virus) and toxic synovitis was made. The laboratory evaluation that day included a erythrocyte sedimentation rate, C-reactive protein, immunoglobulins, Complement 3, Complement 4, liver function tests, rheumatoid factor, creatinine kinase, and viral titers including Epstein-Barr virus IgG. These were to screen for viruses, inflammatory bowel disease, rheumatological disease and possible immunodeficiency. These were all found to be negative. The consulting physician recommended to the private physician to monitor the patient closely and if the fevers returned to possibly evaluate for thyroid disease and tularemia. Discussion Fever is a common concern for parents and for health care providers alike. It is defined as a temperature > 100.5° F or 38.0° C usually determined rectally. Fever by itself rarely causes a problem for children unless it is extreme, i.e. > 106° F or 41.1° C . However, fever says that something is not right with the body and that the body is reacting to it, usually as a self-protective mechanism. The differential diagnosis is extensive but self-limited illnesses predominate. Careful history and physical examination along with judicious use of laboratory testing and careful monitoring of the patient for new or changing symptoms usually elucidates a reason for the fever. Common definitions: Fever without localizing signs or fever without a source indicate a fever whose cause cannot be found currently after careful history and physical examination and does not meet the criteria for fever of unknown origin. Most occur for < 1 week. Fever of unknown origin is a fever at least twice per week that lasts more than 3 weeks without associated signs of acute toxicity with a basic laboratory evaluation that is negative. Fever in a neonate is a fever without localizing signs in a neonate usually < 28 days but some people extend the timing to < 3 months of age. Learning Point The differential diagnosis of fever includes: Allergic Drug reaction - malignant hyperthermia Vaccine reaction Serum sickness Dermatologic Ectodermal dysplasia Immunologic Agammaglobulinemia Hypergammaglobulinemia Infection (by location) Cardiac Endocarditis Myocarditis Pericarditis Dermatologic Cellulitis Exanthems (see also Systemic below) Bacterial Meningococcemia Rocky Mountain spotted fever Scarlet fever Syphilis Others Viral Coxsackie Enterovirus Roseola Rubeola Rubella Varicella Many others Gastrointestinal Abscess, intraabdominal Appendicitis Cholangitis Gastroenteritis, acute Hepatitis Mesenteric adenitis, acute Pancreatitis Peritonitis Genitourinary Abscess, perinephric Epididymitis/orchitis Salpingitis/tubo-ovarian abscess Prostatitis, acute Pyelonephritis Musculoskeletal Septic arthritis Myositis Osteomyelitis Neurologic Abscess Encephalitis Meningitis Ophthalmological Orbital cellulitis/abscess Periorbital/preseptal cellulitis Respiratory tract Upper respiratory tract Abscess - alveolar, peritonsillar, retropharyngeal and lateral pharyngeal wall Adenitis Croup Epiglottitis Otitis media Mastoiditis Parotitis - acute suppurative, mumps Pharyngitis Sinusitis Stomatitis - gingivostomatitis, herpangina Tonsillitis Lower respiratory tract Abscess Bronchitis Bronchiolitis Pneumonia Tuberculosis, pulmonary Systemic (see also Exanthems above) AIDS/HIV Bacterial sepsis Bacteremia, occult Bacteria Brucellosis Cat-scratch disease Leptospirosis Salmonellosis Tuberculosis Tularemia Chlamydia Lymphogranuloma venereum Psittacosis Fungal Blastomycosis Histoplasmosis Parasitic Malaria Toxoplasmosis Visceral larval migrans Rickettsial Q fever Rocky Mountain spotted fever Viruses Cytomegalovirus Epstein-Barr Hepatitis viruses Metabolic Acute intermittent porphyria Diabetes insipidus, central and nephrogenic Etiocholanolone fever Thyrotoxicity Neoplasm Ewing's sarcoma Hodgkin's lymphoma Leukemia Lymphoma Neuroblastoma Neurologic CNS lesions of the hypothalamus/brainstem Riley-Day syndrome Seizures, prolonged Subdural effusions Poisoning/toxins Atropine Amphetamine Cocaine LSD Salicylates Other drugs with anticholinergic effects, i.e. anti-depressants Vasculitic Acute rheumatic fever Dermatomyositis/polymyositis Henoch-Schonlein purpura Juvenile rheumatoid arthritis Kawasaki Disease Mixed connective tissue disorder Polyarteritis nodosa Stevens Johnson Systemic lupus erythematosus Other Caffey's disease Dehydration Crush injuries Factitious/malingering Familiar Mediterranean fever Heat illness and heat stroke Hemolysis, intravascular Hemorrhage into enclosed spaces Inflammatory bowel disease PFAFA syndrome - periodic fever, aphthous ulcers, pharyngitis and adenopathy Sarcoid Questions for Further Discussion 1. What laboratory testing should be included in the outpatient investigation of fever without a source? 2. What laboratory testing should be done for a fever in a neonate? Related Cases Disease Fever Fever without localizing signs Symptom/Presentation Fever and Fever of Unknown Origin Limp Pain Sore Throat Specialty General Pediatrics Infectious Diseases Orthopaedic Surgery and Sports Medicine Pathology Age School Ager To Learn More To view pediatric review articles on this topic from the past year check PubMed. Information prescriptions for patients can be found at MedlinePlus for this topic: Fever and at Pediatric Common Questions, Quick Answers for this topic: http://www.virtualpediatrichospital.org/patients/cqqa/feverlevel.shtml To view current news articles on this topic check Google News. To view images related to this topic check Google Images. Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:90-95. Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1998:31-39. Rudolph CD, et.al. Rudolph's Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:893-895. Woodhead JC. Pediatric Clerkship Guide. Mosby. St. Louis MO, 2003:250-256. Feigin RD, Cherry JD, Demmler GJ, Kaplan SL. Textbook of Pediatric Infectious Diseases. 5th edit. Volume 1. Saunders, Philadelphia, PA. 2004;825,831. ACGME Competencies Highlighted by Case Patient Care 1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors. 2. Essential and accurate information about the patients' is gathered. 3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made. 4. Patient management plans are developed and carried out. 5. Patients and their families are counseled and educated. 7. All medical and invasive procedures considered essential for the area of practice are competently performed. 8. Health care services aimed at preventing health problems or maintaining health are provided. 9. Patient-focused care is provided by working with health care professionals, including those from other disciplines. Medical Knowledge 10. An investigatory and analytic thinking approach to the clinical situation is demonstrated. 11. Basic and clinically supportive sciences appropriate to their discipline are known and applied. Interpersonal and Communication Skills 19. The health professional works effectively with others as a member or leader of a health care team or other professional group. Systems Based Practice 23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known. 24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced. Author Donna M. D'Alessandro, MD Professor of Pediatrics, Children's Hospital of Iowa Date August 27, 2007 (Source: PediatricEducation.org)

Google says the number of messages sent by spammers is flat, and may even be declining, which suggests that spammers are getting discouraged by spam filters. But other experts disagree with Google experience and say that spam attempts are still climbing.

A Google contest aims to entice teenagers into the open-source programming realm.

The meaning of Verizon's about-face; searching for the next Eric Clapton on Guitar Hero; and will a Green Google be a success?

Google launched a location service for mobile users on Wednesday that doesn't rely on GPS.Google Maps with My Location, currently in beta, locates users who don't have GPS-enabled phones based on their location to nearby cell towers. The result isn't as accurate as GPS but works for people who lack the positioning technology in their phones."It helps users speed up search by showing the general neighborhood they're in," said Steve Lee, product manager at Google for the service. Without the location service, users must type in their address or neighborhood in order to find nearby businesses using Google Maps.Google Maps with My Location will use GPS data to locate the user if the phone has the capability. But even for users of GPS-enabled phones, the cell location service might be useful, Lee said. That's because the cell tower feature works better indoors than GPS, it doesn't drain the phone battery as quickly and can bring up a result quicker, he said.The service could be useful to a person who might be traveling in an unfamiliar city and looking for restaurants or other businesses. A user pulls up Google Maps and hits the zero key on the phone. A blue dot will appear on the map in the user's location. If the service used GPS in the phone, the blue dot will be solid. If the service used cell towers to determine the location, the blue dot will have a halo around it, indicating that the location isn't precise. The user can then search for nearby businesses.Google says the cell tower technique will locate the user within about 1000 meters. It doesn't use triangulation, which calculates a user location based on the user's distance to three nearby towers. Instead, it essentially shows the range of the tower that the user's phone is connecting to.But the accuracy should improve as more people use the service, Lee said. That's because Google is keeping a database of location queries, minus any personal information like individual phone numbers or names. That will allow Google to learn more precise information about the range of each tower so that it can deliver a more accurate location area to users. The coverage area of cell towers can vary from about a quarter of a mile to several miles based on whether the tower is in an urban or rural area.For now, Google Maps with My Location doesn't feature any advertising, but it could in the future. "This product makes a lot of sense for advertising," Lee said.In order to use the service, phone owners must download a free application from Google. The application will work on BlackBerry, Windows Mobile, and Symbian phones as well as many phones that support Java. A few notable exceptions include the Samsung Blackjack, Moto Q, and Palm Treo 700W, which don't support the APIs Google requires to find cell towers, Lee said.

Verizon Wireless' decision to open its network to outside mobile devices and applications has won praise from several groups, including past critics.Verizon Wireless officials announced Tuesday they would open up their network to any devices and software customers want to use by the second half of 2008. Any device that passes a minimal connectivity test will be allowed on the Verizon Wireless network, officials said.That announcement drew applause from a wide variety of groups. Public Knowledge, a consumer rights group that has pushed for open network regulations from the U.S. Congress or the Federal Communications Commission, said it was "cautiously optimistic" about Verizon's decision.Verizon's decision could lead to "a more open network in the wireless industry at large," said Gigi Sohn, Public Knowledge's president. Wireless carriers have fought an FCC decision to require open access on a portion of spectrum in the 700MHz band to be auctioned starting in January, she noted."The Verizon announcement, however, is very limited," Sohn added. "If other carriers don't follow the same model, then consumers will still find their phones tied to a specific technology or wireless company. In order for an open network to become a reality, all carriers will have to participate."Verizon will still decide what phones can operate on its network, she said. Public Knowledge would prefer to have a third party decide what phones can operate on the Verizon network, she said.She also has continuing questions about prices. If Verizon continues to offer its preferred mobile phones at a discount, "then the adoption of the open model will be minimal, absent a rapid decline in cell phone prices," Sohn said. "We need to know whether the rates for Verizon service plans will vary for those with subsidized phones and for those customers with a phone bought elsewhere."Others were less guarded with their praise.Verizon's announcement, combined with the Google-led Open Handset Alliance, is a "significant" step toward the goal of more open wireless networks, FCC Chairman Kevin Martin, said in a statement."As I noted when we adopted open network rules for our upcoming spectrum auction, wireless customers should be able to use the wireless device of their choice and download whatever software they want onto it," Martin added. "I continue to believe that more openness -- at the network, device, and application level -- helps foster innovation and enhances consumers' freedom and choice in purchasing wireless service. I am optimistic that Verizon Wireless's commitment along with the upcoming spectrum auction will ensure an exciting new era in wireless technology for the benefit of all consumers."Solveig Singleton, an adjunct senior fellow with Maryland think tank the Free State Foundation, said Verizon's voluntary decision makes more sense than open network regulations, such as net-neutrality rules pushed by Public Knowledge and other groups."Requiring openness or neutrality beyond the basics now supported by demand would needlessly make development far more costly and slow," she said. "A company that wants to invent a new type of phone with cutting-edge features already has a good bit to think about without having to worry about new phones and networks being simultaneously built by everyone else."Many proposed net-neutrality rules would require wireless and broadband providers to treat all network traffic equally, she said."Mandate 'open' and 'neutral' everywhere all the time for everything, and innovation will slow to a snail's pace and network traffic will jam," she added. "Competition between operators to offer innovative combinations of services at special prices would become almost impossible. In this fast-changing context, a regulatory command to treat all traffic all the same is just a bad idea."Also praising Verizon's decision were Funambol, a developer of open-source calendar and messaging tools for mobile phones, and the New America Foundation, a think tank that has pushed for open access rules on the 700MHz spectrumThe FCC and Google deserve credit for pushing the issue forward, said Michael Calabrese, director of New America's Wireless Future Program."This appears to be a move to head off market entry and new wireless competition from Google and other Internet companies that would result if the incumbent carriers were unwilling to meet minimal FCC consumer choice requirements," he said in an e-mail.

AFP - Google on Wednesday released upgraded mapping software that figures out the general vicinity a mobile telephone is in based on which transmission tower it is using.

PC World - Google Maps With My Location, a service for mobile users that doesn't rely on GPS, is now in use by Google.

Light relief for users Google has added a "terrain" feature to its Google Maps service, giving a nice bit of light relief to its hitherto decidedly flat cartographical offering:…

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