A Diagnostic Challenge: Necrotizing Retropharyngeal Lymphadenitis With Microbiologically Supported Multifocal Pseudomonas aeruginosa Infection and a Tularemia-Like Presentation.

Necrotizing retropharyngeal lymphadenitis can cause rapidly progressive airway compromise and systemic illness in young children. We describe a two-year-old boy with no previously recognized chronic disease or immune disorder who presented with fever, stridor, hypoxemia, cytopenias, markedly elevated inflammatory markers, and a necrotic right-cheek lesion. Progressive airway compromise required endotracheal intubation, and contrast-enhanced computed tomography revealed bilateral necrotic retropharyngeal lymph nodes or collections with surrounding edema, as well as cervical lymphadenopathy. He subsequently developed septic shock with respiratory, cardiovascular, and coagulation dysfunction. A household rabbit had died four days before presentation, raising concern for tularemia, although a bite or scratch could not be confirmed. Tularemia serology obtained within the first week of illness was negative and was not repeated; therefore, tularemia could not be definitively excluded. During admission, additional papulopustular skin lesions and otorrhea developed.