An 18-month-old girl is brought to the office by her parents due to difficulty breathing. The patient has had a runny nose and congestion since yesterday. Coughing started last night and has worsened throughout the day. The patient is drinking fluids and voiding is normal. She was hospitalized at age 4 months for bronchiolitis and had a recent urgent care visit after putting a bead in her nose. The patient takes no daily medications and vaccinations are up to date. Temperature is 37.8 C (100 F), blood pressure is 90/60 mm Hg, and respirations are 30/min. Pulse oximetry is 97% on room air. During examination, the patient coughs and cries but is easily consoled. The cough is harsh, and inspiratory stridor is heard when she is crying but resolves at rest. The lungs are clear to auscultation. Which of the following is the most likely cause of the patient's symptoms?

Question

An 18-month-old girl is brought to the office by her parents due to difficulty breathing.  The patient has had a runny nose and congestion since yesterday.  Coughing started last night and has worsened throughout the day.  The patient is drinking fluids and voiding is normal.  She was hospitalized at age 4 months for bronchiolitis and had a recent urgent care visit after putting a bead in her nose.  The patient takes no daily medications and vaccinations are up to date.  Temperature is 37.8 C (100 F), blood pressure is 90/60 mm Hg, and respirations are 30/min.  Pulse oximetry is 97% on room air.  During examination, the patient coughs and cries but is easily consoled.  The cough is harsh, and inspiratory stridor is heard when she is crying but resolves at rest.  The lungs are clear to auscultation.  Which of the following is the most likely cause of the patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d607_b975_bc81_09bc03232cb7_MD0003_00 This patient with upper respiratory symptoms (eg, congestion, rhinorrhea) now has a harsh cough and inspiratory stridor, symptoms suggestive of croup. Croup is a viral infection caused by the parainfluenza virus and is most common in children age 6 months to 3 years. The virus spreads from the nasopharyngeal mucosa to the larynx and trachea, causing edema and narrowing of proximal trachea (ie, subglottis). Inflammation of the cricoid cartilage creates a partial upper airway obstruction, resulting in a high-pitched noise during inspiration, hoarseness, and a barky cough. Although the diagnosis is usually clinical, x-ray may reveal subglottic narrowing, or steeple sign. steeple sign Mild croup is characterized by a barky cough with or without the stridor that is present only with agitation (eg, crying) and not at rest. It is managed with a single dose of corticosteroids (eg, dexamethasone) to decrease airway edema. More severe obstruction that causes stridor at rest is treated with corticosteroids and nebulized epinephrine. Most patients' croup improves within a few days. (Choice A) Bronchoconstriction and small airway inflammation occur in patients with asthma and bronchiolitis, which present with cough and wheezing, not stridor. (Choice C) Inflammation of the epiglottis and aryepiglottic folds describes epiglottitis, a severe infection caused by Haemophilus influenzae type b; it is rare in immunized children. Although patients often have stridor and respiratory distress, they typically appear ill and have a high fever, difficulty swallowing, and drooling, none of which are seen in this patient. (Choice D) Foreign body (FB) aspiration presents with sudden-onset respiratory distress, often following an acute choking episode. Laryngeal FBs may cause inspiratory stridor, but bronchial FBs cause focal wheezing and asymmetric breath sounds. This patient's preceding congestion and rhinorrhea and normal lung examination make bronchial FB aspiration unlikely. (Choice E) Laryngeal vascular ring is a congenital malformation in which an aberrant vessel encircles the airway, causing airway narrowing and chronic stridor. This patient's acute onset of cough and stridor are indicative of an infectious process, such as croup. Educational objective: Croup is a viral infection in which edema and narrowing of the proximal trachea result in a barky cough and inspiratory stridor. Treatment with corticosteroids with or without nebulized epinephrine decreases airway inflammation. References: Croup. (http://www.ncbi.nlm.nih.gov/pubmed/25263284)

An 18-Month-Old Girl Is Brought to the Office by Her