A 32-year-old right-handed female veterinarian presented with a spontaneous, painless swelling of the right supraclavicular fossa and lower neck. She denied fever, night sweats, or weight loss. Before this presentation she was in excellent health. The physical examination showed a pronounced asymmetry of the supraclavicular fossae ; the vital signs were normal, and there was no lymphadenopathy or hepatosplenomegaly.
Laboratory investigations including a neutrophil count and C-reactive protein, as well as antibody tests for toxoplasmosis and Bartonella henselae (because of her profession), were all within normal limits.
Axial fluid-sensitive and contrast-enhanced magnetic resonance imaging revealed gross edema (arrow) without signs of infection. A coronal fluid-sensitive image showed a lymphatic vessel with discontinuity
Upon detailed history, the patient reported that 1 day before presentation she had been to a seasonal beer-drinking event (“Oktoberfest”) at which she engaged in a friendly competition testing her ability to horizontally extend a filled 1-liter beer stein with her right hand for as long as possible; this vigorous isometric exertion was performed to exhaustion and was the likely cause of the localized ipsilateral edema, possibly related to the extravasation of lymphatic fluid.
We recommended sleeping in a semi-reclining position and the avoidance of stooping. The edema resolved within 2 days, but there was another episode of transient painless right-sided neck edema precipitated by carrying a heavy shopping bag 10 days after the initial event. Subsequently, there was no further recurrence, indicating an excellent prognosis without specific treatment.
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-Annika Jantze, MD, Gustav Andreisek, MD, MBA, Michael A. Fischer, MD, Christlieb Haller, MD
This article originally appeared in the December 2015 issue of The American Journal of Medicine.
