Bilateral Posterior Neck Masses in an 8-Year-Old Boy: A Case of Pediatric Tularemia of the Head and Neck

An 8-year-old boy presented to his pediatrician in southern New Jersey with fever, tender bilateral posterior cervical lymphadenopathy, sore throat, and extreme fatigue with refusal to walk for 3 days. He tested positive for streptococcus of the pharynx and was treated with amoxicillin. Six days later, he was changed to amoxicillin–clavulanate for failure to improve. Two days later, he presented to an emergency department for persistent fever, worsening cervical posterior lymphadenopathy, and a diffuse macular rash of the face, trunk, chest, and palms. At this visit, his mother recalled a tick bite on his scalp prior to the onset of symptoms that had resulted in a small eschar.