A 3-year-old boy is brought to the emergency department with breathing difficulty and drooling that have worsened rapidly over the last 8 hours. He has no chronic medical conditions. Temperature is 39.4 C (102.9 F). Examination shows a toxic-appearing patient leaning forward while sitting on the bed; he has inspiratory stridor and suprasternal retractions. There are pooled oral secretions, and the patient is unable to swallow. Which of the following is the greatest risk factor for this patient's condition?

Question

A 3-year-old boy is brought to the emergency department with breathing difficulty and drooling that have worsened rapidly over the last 8 hours.  He has no chronic medical conditions.  Temperature is 39.4 C (102.9 F).  Examination shows a toxic-appearing patient leaning forward while sitting on the bed; he has inspiratory stridor and suprasternal retractions.  There are pooled oral secretions, and the patient is unable to swallow.  Which of the following is the greatest risk factor for this patient's condition?

Quizplus · Accepted Answer

11ec160b_389d_0b4b_9249_e53a646ac0c6_MD0001_00 This ill-appearing patient likely has epiglottitis, a rapidly progressive, life-threatening infection that classically presents with high fever, dysphagia, and drooling (often with pooled oral secretions) in young children. Older children and adults may initially have severe sore throat. Narrowing of the larynx causes signs of respiratory distress (eg, retractions) with inspiratory stridor, and patients classically assume tripod positioning (ie, leaning forward with the neck extended) to maximize airflow. Haemophilus influenzae type b (Hib) was historically the most common pathogen that caused epiglottitis, but routine immunization in infancy has greatly decreased its incidence. Individuals with incomplete vaccination against Hib remain at greatest risk of developing epiglottitis. Pathogens implicated in immunized children more commonly include nontypeable H influenzae and Streptococcus pneumoniae, in addition to rare cases of Hib. (Choice A) A foreign body obstructing the larynx or trachea can present with stridor and acute respiratory distress. However, fever and pooled oral secretions would not be expected. (Choice B) Anaphylaxis, triggered by IgE-mediated mast cell degranulation, causes acute airway edema and respiratory distress, but other allergic symptoms (eg, hives, angioedema) are usually present. In addition, anaphylaxis does not cause fever. (Choice D) The incidence of epiglottitis is not increased with international travel in an immunocompetent, vaccinated child. Incomplete vaccination against Hib remains the greatest risk factor. (Choice E) Secondhand smoke exposure is a risk factor for asthma, which can present with acute respiratory distress due to lower airway hyperreactivity and inflammation. Examination would reveal wheezing due to bronchoconstriction, not signs of upper airway obstruction (eg, stridor). Educational objective: Epiglottitis causes rapidly progressive airway obstruction and classically presents with fever, dysphagia, drooling, stridor, and tripod positioning. Individuals with incomplete immunization against Haemophilus influenzae type b are at greatest risk. __________ References: Review of epiglottitis in the post Haemophilus influenzae type-b vaccine era. (http://www.ncbi.nlm.nih.gov/pubmed/30207030)

A 3-Year-Old Boy Is Brought to the Emergency Department with Breathing