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Management: If the node is fluctuant, aspiration provides useful etiologic information and speeds the rate of
resolution. Children who fail to respond to empiric antibiotic therapy and children with tuberculosis risk factors
who present with adenitis should have a TST placed. Children with cervical adenitis who are otherwise healthy
should receive an antibiotic effective against S. aureus and the GAS. While clindamycin (10 mg/kg/dose three
times daily; maximum: 600 mg/dose) has activity against both pathogens, trimethoprim-sulfamethoxazole (TMPSMZ) will not offer GAS coverage. The decision about which oral antibiotic to select depends on the level of
methicillin-resistant S. aureus (MRSA) in a community. Indications for inpatient admission and parenteral
antibiotics include: toxic appearance; young age (<3 months); immunocompromised host; suspicion of deeper neck
extension; development of a draining sinus track; or failure to improve with outpatient oral antibiotic therapy. For
these children, clindamycin (10 to 13 mg/kg every 8 hours; maximum: 600 mg/dose) or vancomycin (15 mg/kg
every 8 hours; maximum: 2 g/dose) offers alternatives in the face of penicillin and/or cephalosporin allergy or in
areas where coverage for MRSA must be considered. Standard precautions should be used unless children have
draining lesions (in which case contact precautions should be used) or if children are suspected of having
tuberculosis lymphadenitis (in which case airborne precautions should be used until pulmonary involvement is
excluded).

Other Neck Infectious Emergencies
Lemierre Syndrome
Lemierre syndrome refers to a deep neck abscess with a contiguous septic thrombophlebitis of the internal jugular
and septic pulmonary emboli. The most common cause historically has been Fusobacterium necrophorum; in
recent years, S. aureus has been the most common etiology. Examination is notable for a tender cord in the lateral
neck and dyspnea is common as the number of septic pulmonary emboli increases. The diagnosis can be made by
CT neck with contrast-showing flow voids in the jugular; apical cuts through the lungs on neck CT may show the
embolic lesions. Children with suspected Lemierre’s should receive broad-spectrum antibiotics covering both
MRSA and anaerobes (e.g., vancomycin plus metronidazole).
Cat-scratch Disease
Cat-scratch disease, caused by Bartonella henselae, is caused by cat scratches, cats licking abraded skin, or from
the bite of infected cat fleas. These most commonly occur to the upper extremities and result in tender, fluctuant
axillary or epitrochlear lymphadenitis, but cervical adenopathy can be seen if scratches or bites occur to the face.
In some pediatric series, Bartonella and EBV are the most common causes of fever of unknown origin. Diagnosis
is based on history (cat, especially kitten, exposure), examination (slowly healing papule at inoculation site), and
serologies. While most lesions will resolve in 1 to 2 months, antibiotics may decrease symptom duration and are

recommended for immunocompromised patients. Optimal antibiotics are unclear; rifampin, azithromycin, TMPSMZ, and fluoroquinolones have all been utilized. Standard precautions should be used.

RESPIRATORY TRACT INFECTIOUS EMERGENCIES
Upper Respiratory Tract Infectious Emergencies
Goals of Treatment
Infections in the neck can rapidly enter other tissue planes that can result in spread to contiguous structures,
including compromising the airway or neck vasculature. Clinicians need to be cognizant that while most upper
airway infections are relatively benign (e.g., pharyngitis), some can progress from benign etiologies to lifethreatening complications (e.g., Lemierre syndrome). The clinical manifestations, diagnosis, and treatment of
upper respiratory tract infections are summarized in Table 94.12 .
CLINICAL PEARLS AND PITFALLS