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. Pseudomonas aeruginosa was isolated from ear discharge, a deep tracheal aspirate, and a pustular skin lesion, supporting a clinically significant multifocal infection at the sampled sites. Blood cultures remained negative, and the retropharyngeal lesions were not sampled; therefore, their microbiological etiology could not be established. The child improved with antimicrobial therapy and multidisciplinary management. This case highlights the importance of distinguishing microbiologically confirmed infection from anatomically plausible but unproven causal associations when epidemiologic, radiologic, and microbiological findings do not fully align.