A 35-year-old woman comes to the emergency department with fever, chills, and sore throat for the past 4 days. Except for a temperature of 38.3 C (101.0 F), her other vital signs are within normal limits. Examination shows pharyngeal and tonsillar erythema without exudates and bilateral tender cervical lymphadenopathy. The remainder of the examination is normal. Point-of-care testing for group A streptococcus is negative. The patient is diagnosed with viral pharyngitis and prescribed symptomatic therapy. She returns 3 days later due to a persistent fever, sore throat, and progressive dysphagia.
Her temperature now is 38.9 C (102.0 F), blood pressure is 118/78 mm Hg, pulse is 90 /min, and respirations are 16 /min. Physical examination remains unchanged from 3 days ago except that she appears more ill. Point-of-care testing for the Epstein-Barr virus is negative.
Which of the following is the most appropriate next step in management?

Question

A 35-year-old woman comes to the emergency department with fever, chills, and sore throat for the past 4 days.  Except for a temperature of 38.3 C (101.0 F), her other vital signs are within normal limits.  Examination shows pharyngeal and tonsillar erythema without exudates and bilateral tender cervical lymphadenopathy.  The remainder of the examination is normal.  Point-of-care testing for group A streptococcus is negative.  The patient is diagnosed with viral pharyngitis and prescribed symptomatic therapy.  She returns 3 days later due to a persistent fever, sore throat, and progressive dysphagia.
Her temperature now is 38.9 C (102.0 F), blood pressure is 118/78 mm Hg, pulse is 90 /min, and respirations are 16 /min.  Physical examination remains unchanged from 3 days ago except that she appears more ill.  Point-of-care testing for the Epstein-Barr virus is negative.
Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec193a_95eb_0ecf_853d_0d3ced1715e7_MD0002_00 This patient presents with symptoms of worsening acute pharyngitis with dysphagia that is concerning for epiglottitis, a rare but potentially life-threatening airway infection. Epiglottitis is a cellulitis of the epiglottis that results from bacteremia and/or direct bacterial invasion from the posterior nasopharynx. The clinical features in adults (shown above) usually has a slower progression than those seen in children. A lateral neck x-ray can be diagnostic, but should only be ordered in stable patients without impending airway obstruction (e.g., stridor). Abnormal x-ray findings of epiglottitis include a swollen and enlarged epiglottis > 8 mm in adults (the thumbprint sign), loss of vallecular air space, and thickened aryepiglottic folds > 7 mm in adults. Diagnosis is confirmed with direct visualization of an erythematous and edematous epiglottis on laryngoscopy, but the pharynx should be examined carefully to avoid causing airway obstruction. The common causative organisms include Hemophilus influenzae, β-hemolytic streptococci, Streptococcus pneumoniae, and Staphylococcus aureus. Combination therapy with ceftriaxone and vancomycin is the preferred empiric antibiotic regimen. Hemophilus influenzae Streptococcus pneumoniae Staphylococcus aureus (Choice A) Point-of-care testing for EBV, if performed after 5 days of clinical illness, has a sensitivity of around 90%. EBV serology is even more sensitive than rapid point-of-care testing. However, this patient is in a very low risk group for EBV (as she is 35 years old) and the median age is < 21 years for presentation. Furthermore, most adults in the United States have been infected with EBV well before the age of 35 years. (Choice B) Rapid antigen testing for group A streptococcus has a sensitivity between 85-90%. Culture is the gold standard with a sensitivity of > 95%. However, the incidence of group A strep in adults is < 10%, so the culture in this patient is unlikely to add to the clinical decision making process. (Choice C and E) Life threatening conditions should be ruled out first. Educational objective: Epiglottitis should be suspected in patients when the severity of sore throat is out of proportion to the findings on oropharyngeal examination. Drooling and stridor are seen in less than 40% of the patients. Odynophagia and dysphagia are much more common (>90%). __________ References: Acute supraglottitis in adults. (http://www.ncbi.nlm.nih.gov/pubmed/21675584)

A 35-Year-Old Woman Comes to the Emergency Department with Fever