Epiglottitis
Congenital Rubella Syndrome
Streptococcal Infection Secondary to Varicella

 Epiglottitis
JEFF ALLEN BECK, MD
Grand Rapids Medical Education and Research Center, Mich

JERI WEYHER KESSENICH, MD
Helen DeVos Children’s Hospital, Grand Rapids, Mich

A 17-month-old girl awoke with drooling, cough, respiratory distress, and a muffled cry and was brought to the emergency department. She had no nausea, vomiting, or diarrhea and no history of choking, aspiration, or airway problems.

On examination, the patient was in significant respiratory distress with audible stridor during inhalation and exhalation. While in an upright-seated position, the infant was noted to be leaning forward. Rectal temperature was 40.5°C (105°F); respiration rate, 40 breaths per minute; and pulse rate, 202 beats per minute. Oxygen saturation on room air was normal. Inhalation treatments were administered.

Anteroposterior and lateral neck radiographs demonstrated an enlarged epiglottis with effacement of the vallecula and thickening of the aryepiglottic folds and pharyngeal edema. Laryngoscopy demonstrated a severely edematous and erythematous epiglottis. The true vocal cords were normal. Aerobic and anaerobic culture specimens from the surface of the epiglottis were obtained.

The patient was transferred to the pediatric critical care unit in stable condition and placed on a mechanical ventilator. A review of systems at this point was normal.

The mother reported that the patient had no significant medical or surgical history and no sick contacts. The infant was born at term via spontaneous vaginal delivery without complications. She had not yet received her final Haemophilus influenzae type b (Hib) or pneumococcal conjugate vaccinations; all other immunizations were up-to-date. She lived at home with her mother and 2 siblings.

Laboratory data revealed an elevated peripheral blood white blood cell count of 16,700/μL, with 38 segmented neutrophils, 1 band, 51 lymphocytes, 8 monocytes, and 2 eosinophils on manual differentiation. The culture was positive for a few Streptococcus pyogenes colonies. A nasal swab was negative for viral antigens (adenovirus; influenza A and B; parainfluenza viruses types 1, 2, and 3; and respiratory syncytial virus). A peripheral blood culture was negative.

Since the routine administration of Hib conjugate vaccine, the incidence of epiglottitis, a presentation of invasive Hib disease in children younger than 5 years, declined from 100 cases in 100,000 children in 1988 to 0.3 cases per 100,000 children in 2000.¹ In 2006, 93% of children aged 19 to 35 months had received at least 3 doses of the Hib vaccine.²

Bacteria other than Hib have been associated with epiglottitis in children. These include Haemophilus influenzae types A and F; Streptococcus pneumoniae; Staphylococcus aureus; and β-hemolytic streptococci groups A, B, C, and F.3 Viral causes of epiglottitis are rare and associated with infection by herpes simplex virus type 1, parainfluenza virus type 3, and influenza virus type B. Thermal injury also may cause epiglottitis.⁴

Most children with epiglottitis recover without residual airway effects when the appropriate antibiotics are administered and the airway is secured. Most deaths result from failure to secure the airway once the condition is suspected.⁵

This patient was extubated on hospital day 3 after receiving ceftriaxone (50 mg/kg/d) and a total of 6 doses of dexamethasone given every 6 hours. Intravenous ceftriaxone was continued for a total of 7 days. After 48 hours of normal oral intake, the child was discharged with a prescription for a 5-day course of extended-release amoxicillin/ clavulanate (45 mg/kg bid). The child was completely well at the follow- up visit 5 days later.

REFERENCES:
1. Centers for Disease Control and Prevention. Progress toward elimination of Haemophilus influenzae type b invasive disease among infants and children—United States, 1998-2000. MMWR. 2002;51: 234-237.
2. Centers for Disease Control and Prevention. National, state, and local area vaccination coverage among children aged 19-35 months—United States, 2006. MMWR. 2007;56:880-885.
3. Briggs WH, Altenau MM. Acute epiglottitis in children. Otolaryngol Head Neck Surg. 1980;88: 665-669.
4. Grattan-Smith T, Forer M, Kilham H, Gillis J. Viral supraglottitis. J Pediatr. 1987;110:434-435.
5. Damm M, Eckel HE, Jungehülsing M, Roth B. Airway endoscopy in the interdisciplinary management of acute epiglottitis. Int J Pediatr Otorhinolaryngol. 1996;38:41-51.