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 year The infected node may vary in size from 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