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Case report. A previously healthy 10-year-old girl was seen in the emergency department and was admitted for severe left neck pain and fever after a 2-week history of nasal congestion, low grade fever and sore throat. Her mother had also recently been ill with an upper respiratory tract infection. There was no history of sickle cell anemia, recent medications, pets in the household, recent travel or known exposure to tuberculosis. No human immunodeficiency virus risk factors were identified.
Physical examination revealed an ill-appearing child with a temperature of 38.9°C. Examination of her pharynx revealed asymmetrically enlarged, erythematous tonsils, the left larger than the right, that were nearly touching. There was no evidence of a peritonsillar abscess but the tonsillar crypts were prominent and a thin whitish exudate was present. The uvula appeared congested and erythematous but in midline. Trismus, muffled voice and drooling were absent and the epiglottis was visualized manually and appeared normal. Examination of the neck revealed bilaterally enlarged, tender and warm, jugulodigastric lymph nodes. The lymph nodes on the left side of the neck were larger than the right, were diffusely tender and full and measured 4 by 4 cm. Several discrete, nontender anterior lymph nodes were present bilaterally. The rest of the examination was unremarkable.
Initial laboratory studies revealed a white blood cell count of 31 500/mm3 with 86% neutrophils. IgM and IgG titers against Epstein-Barr virus were negative. A chest radiograph was normal and a throat culture was negative for group A streptococci. Computed tomography of the neck revealed diffuse bilateral cervical adenopathy and a focal lesion (without evidence of gas formation) measuring 1.5 cm in the left lateral retropharyngeal region, consistent with an evolving abscess or phlegmon (Fig. 1). A blood culture drawn before initiation of antibiotic therapy grew S. pneumoniae which was intermediately resistant to penicillin (MIC = 0.5 μg/ml).
Intravenous ticarcillin/clavulanate (3.1 g every 6 h) was administered, and within 24 h the neck pain resolved and the adenopathy and appearance of the pharynx improved markedly. She became afebrile 48 h after initiation of antimicrobial therapy. After 4 days of intravenous ticarcillin/clavulanate therapy, she was discharged home to receive oral clindamycin (MIC = 0.06 μg/ml). A repeat computerized tomography scan of the neck performed at the completion of a 3-week course of oral clindamycin revealed complete resolution of the retropharyngeal infection and cervical adenopathy. Physical examination 1 month after the completion of antimicrobial therapy was normal.
Discussion. Bacterial cervical adenitis and deep neck abscesses in children are usually the result of direct extension of infections that involve the nasopharynx, adenoids, oral cavity and skin.1-6 Predisposing conditions include pharyngitis, tonsillitis, adenoiditis, trauma, sinusitis and dental procedures. Although the pneumococcus commonly colonizes the nasopharynx of infants and children7-11 and is a major cause of sinusitis and otitis media, it is very rarely associated with cervical adenitis and deep neck infection. Recovery of S. pneumoniae from the blood of our patient is strong evidence that this organism was the cause of the adenitis and retropharyngeal space infection.
