A 5-year-old boy is brought to the emergency department by his parents due to sudden-onset difficulty breathing. The patient developed a mild cough and sore throat yesterday; his parents gave him acetaminophen, which improved his throat pain. However, this morning the patient had difficulty breathing and was sitting in bed and leaning forward, refusing to lie down. He takes no medications and has no known allergies. The patient has had no vaccinations. Temperature is 39.1 C (102.4 F), blood pressure is 100/65 mm Hg, pulse is 130/min, and respirations are 46/min. Oxygen saturation is 92% on room air. The patient appears anxious, is drooling, and has inspiratory stridor. The uvula is midline, and there is no oropharyngeal or tonsillar erythema. Lung examination shows transmitted upper airway noises without wheezing or crackles. Which of the following is the most likely diagnosis?

Question

A 5-year-old boy is brought to the emergency department by his parents due to sudden-onset difficulty breathing.  The patient developed a mild cough and sore throat yesterday; his parents gave him acetaminophen, which improved his throat pain.  However, this morning the patient had difficulty breathing and was sitting in bed and leaning forward, refusing to lie down.  He takes no medications and has no known allergies.  The patient has had no vaccinations.  Temperature is 39.1 C (102.4 F), blood pressure is 100/65 mm Hg, pulse is 130/min, and respirations are 46/min.  Oxygen saturation is 92% on room air.  The patient appears anxious, is drooling, and has inspiratory stridor.  The uvula is midline, and there is no oropharyngeal or tonsillar erythema.  Lung examination shows transmitted upper airway noises without wheezing or crackles.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d24e_d02f_bc81_c5741357edec_MD0003_00 Epiglottitis is an uncommon but potentially fatal infection most commonly caused by Haemophilus influenzae type b (Hib). Incidence of epiglottitis has dramatically decreased since widespread vaccination against Hib; therefore, lack of vaccination (as in this case) is a risk factor for development. Presentation includes acute onset of fever with dysphagia, drooling, and respiratory distress. Symptoms often develop over hours without a significant prodrome. Upper airway edema leading to airway obstruction may be indicated by restlessness/anxiety, worsening stridor, and a muffled "hot potato" voice. Patients may also lean forward, as in this case, and hyperextend the neck (tripod position) to maximize airway diameter when significant airway swelling is present. Acute management focuses on securing the airway (eg, intubation) and antibiotic therapy. tripod position (Choice A) Bronchiolitis, a viral infection of the lower respiratory tract, occurs in children age <2 and presents with fever, cough, retractions, and crackles/wheezing. Stridor, a sign of upper airway obstruction, would not be present. (Choice B) Croup (laryngotracheitis), which is most common in children age 6 months to 3 years, presents with hoarseness, stridor, and fever. Croup causes a characteristic "barky" cough, not seen in this patient. In addition, drooling is uncommon in croup, and patients are typically less ill appearing than those with epiglottitis. (Choice C) Diphtheria classically presents with a gradual onset of sore throat, low-grade fever, and an adherent gray, pharyngeal pseudomembrane. Stridor and respiratory distress can develop in severe cases, which also present with marked edema of the posterior pharynx and neck, which is not seen in this case. (Choice E) Foreign body aspiration most commonly presents in infants/toddlers with acute onset of wheezing, stridor, and/or respiratory distress; however, acute aspiration does not cause fever. In addition, foreign body aspiration is less likely after age 3, when children are past the oral exploration stage. (Choice F) Peritonsillar abscess is most common in older children and adolescents and presents with gradual onset of fever, muffled voice, and unilateral tonsillar swelling with uvular deviation. This patient's age, midline uvula, and acute symptom onset make this diagnosis unlikely. Educational objective: Epiglottitis presents with abrupt onset of fever, dysphagia, drooling, and respiratory distress. Signs of impending airway obstruction include anxiety and tripod positioning (ie, upright/forward positioning with neck hyperextension). References: Symptoms and signs differentiating croup and epiglottitis. (http://www.ncbi.nlm.nih.gov/pubmed/21091577) Epiglottitis. (http://www.ncbi.nlm.nih.gov/pubmed/28613691)

A 5-Year-Old Boy Is Brought to the Emergency Department by His