commonly associated with pink to violaceous overlying skin, with “parchment”like texture Systemic manifestations may indicate an underlying immune deficiency Children with suspected mycobacterium infection should have a purified protein derivative (PPD) tuberculin skin test, and chest radiograph performed, though the PPD may be negative in atypical infections A complete excisional biopsy may be necessary to identify and treat the organism definitively Conversely, incision and drainage can result in a draining sinus Treatment with clarithromycin with ethambutol or rifampin may be indicated in children with recurrent disease or incomplete excision Treatment for M tb lymphadenitis is the same as for pulmonary tuberculosis, with to months of antituberculosis chemotherapy Kawasaki disease (mucocutaneous lymph node syndrome) is a vasculitis of unclear etiology (see Chapter 101 Rheumatologic Emergencies ) The vast majority of the cases occur in children younger than years of age, with a peak incidence between 18 and 24 months The illness is classically characterized by a combination of a fever of at least days duration with out of of the following: a single, enlarged, cervical lymph node (>1.5 cm diameter), nonexudative conjunctival injection, oropharyngeal changes (e.g., erythematous mouth, cracked lips, strawberry tongue), erythematous rash, and induration or erythema of the palms and soles Cervical lymphadenopathy is the least common of the presenting signs, however Coronary artery aneurysm can be a long-term complication if left untreated An echocardiogram should be performed to rule out coronary artery aneurysms Immunosuppressive therapy (IVIG) and aspirin should be started in consultation with a rheumatologist if it is suspected Deep space neck infections are potentially serious illnesses that can present with neck mass, fever, dysphagia, sore throat, and pain with neck motion Retropharyngeal abscess (RPA) results from involvement of the paramedian lymph nodes, located in the prevertebral space, which are responsible for drainage of infections of the nasopharynx, paranasal sinuses, and middle ear These nodes tend to atrophy in early childhood, thus, most cases occur in children younger than years old Pain is generally more notable upon neck extension than flexion In contrast, LPAs and PTAs are associated with painful neck rotation, and are generally seen in school-aged children and adolescents These entities share common pathogens, however, including group A streptococcus, anaerobes, or S aureus Lateral neck films with appropriate application (on deep inspiration, with neck in extension) may reveal enlarged prevertebral space in cases of RPAs, though neck CT with contrast provides the most accurate imaging modality for evaluating deep space neck infections Treatment includes monitoring for signs of