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common in developing nations where infants are unprotected because of the lack of maternal immunity. Local
tetanus refers to muscle spasms in areas contiguous to the wound, and can result in generalized tetanus (lockjaw),
with trismus, risus sardonicus, and generalized muscle spasming. The differential diagnosis includes hypocalcemia
and drug reactions. Tetanus is a clinical diagnosis; culture yield is poor. Treatment is tetanus immune globulin
(TIG), with some infiltrated around the wound and the rest administered intramuscularly. Metronidazole
(preferred) or penicillin for 10 to 14 days also is needed. The recommendations for ED management of tetanus
prophylaxis are described in Table 94.11 . It is important that the ED physician asks about tetanus vaccination, as
opposed to assuming that children are up to date on this immunization; a recent national surveillance study found
that only 72% of toddlers were appropriately immunized. Standard precautions should be used.

NECK INFECTIOUS EMERGENCIES
Cervical Lymphadenitis
CLINICAL PEARLS AND PITFALLS
The most common organisms causing cervical lymphadenitis are staphylococci and streptococci.
However, thorough travel and exposure histories should be taken to evaluate for less common
etiologies.
Signs of inflammation also can help differentiate among the causes of localized infectious
lymphadenopathy. Nontender adenopathy should lead the clinician away from most pyogenic causes,
and should increase the index of suspicion for viral upper respiratory infections (URIs) or
mycobacterial disease, depending upon the duration of illness.
Current Evidence
Cervical lymphadenitis is a bacterial infection of the lymph nodes in the neck. This condition must be
distinguished from lymphadenopathy, an enlargement of one or more lymph nodes that occurs with viral
infections, or as a reaction to bacterial disease in structures that drain to the nodes. The most common etiologies
are listed in e-Table 94.6 (see also Chapter 47 Lymphadenopathy ).
Goals of Treatment
Clinical outcomes for children with lymphadenitis include limiting the use of CT among patients with
uncomplicated bacterial lymphadenitis.
Clinical Considerations
Clinical recognition: The child with cervical lymphadenitis is usually noted to have swelling in the neck. If
sufficiently old, he or she will complain of pain. Fever occurs only occasionally, more often in children younger

than 1 year. The infected node may vary in size from 2 cm to more than 10 cm. Initially, it has a firm consistency,
but fluctuance develops in about 25% of the infected nodes. The skin overlying the node becomes erythematous,
and there may be associated edema. Children with nontuberculous mycobacterial infections may have nontender
adenopathy with violaceous discoloration of the overlying skin.
Triage considerations: Children with lymphadenitis should be promptly assessed for deep neck infections and
for infections that may affect the airway. Lymphadenitis should be considered in the differential diagnosis of a
child with a painful neck mass. Associated toxic appearance or pain out of proportion to the examination may
imply a deeper extension of the infection and demand emergent surgical consultation and empiric broad-spectrum
antibiotic therapy.
Clinical assessment: The WBC count is usually normal but may be elevated in the younger, febrile child.
Aspiration of the node often identifies the organism by both Gram stain and culture, even if fluctuance is not
appreciated. Children with infections from Mycobacterium tuberculosis usually react to the TST and may have
findings compatible with tuberculosis seen on chest radiograph. Complications of bacterial adenitis are unusual.
Organisms such as S. aureus and group A streptococci (GAS) can spread locally if unchecked. A draining sinus
tract may develop in untreated children with atypical mycobacterial adenitis. Recurrence of infection suggests a
local anatomic abnormality (e.g., branchial cleft cyst laterally or thyroglossal duct cyst in the midline) or
immunocompromising conditions such as chronic granulomatous disease.