A 4-year-old boy is brought to the clinic due to sore throat. He first became ill 2 days ago with fever and rhinorrhea. This morning, he developed a severe sore throat and refused to eat his midmorning snack. The patient has type 1 diabetes mellitus and has been hospitalized twice in the last year for diabetic ketoacidosis. He has had no childhood vaccinations. His mother is a smoker and often smokes cigarettes inside the house. The patient is at the 50th percentile for height and 99th percentile for weight. Temperature is 39.4 C (103 F). While sitting on the examination table, the patient appears distressed and leans forward with his chin thrust forward. Tympanic membranes are clear. Oropharyngeal examination shows multiple dental caries. The tonsils are mildly erythematous and 1+ bilaterally. The submandibular space and neck are soft. Lung examination reveals no wheezes or crackles. Which of the following is the most likely risk factor for this patient's current condition?

Question

A 4-year-old boy is brought to the clinic due to sore throat.  He first became ill 2 days ago with fever and rhinorrhea.  This morning, he developed a severe sore throat and refused to eat his midmorning snack.  The patient has type 1 diabetes mellitus and has been hospitalized twice in the last year for diabetic ketoacidosis.  He has had no childhood vaccinations.  His mother is a smoker and often smokes cigarettes inside the house.  The patient is at the 50th percentile for height and 99th percentile for weight.  Temperature is 39.4 C (103 F).  While sitting on the examination table, the patient appears distressed and leans forward with his chin thrust forward.  Tympanic membranes are clear.  Oropharyngeal examination shows multiple dental caries.  The tonsils are mildly erythematous and 1+ bilaterally.  The submandibular space and neck are soft.  Lung examination reveals no wheezes or crackles.  Which of the following is the most likely risk factor for this patient's current condition?

Quizplus · Accepted Answer

11ec25c8_d68f_fc40_bc81_a1032c2aec57_MD0003_00 Epiglottitis is a potentially life-threatening infection of the epiglottis and adjacent pharyngeal structures. Most cases are thought to arise via pathogen penetration into the epiglottal epithelial layer after injury (eg, viral infection, mechanical trauma from food). Pathogens are typically nasopharyngeal bacteria, such as Haemophilus influenzae species and Streptococcus species. Although rates of epiglottitis due to Haemophilus influenzae type b (Hib) have dramatically declined since widespread immunization against Hib, it remains the most commonly isolated pathogen. Therefore, lack of vaccination is a risk factor for the development of epiglottitis. Immune deficiency is a less strongly associated risk factor for pediatric epiglottitis. Symptoms of epiglottitis include rapid onset of fever, sore throat, muffled voice, drooling, and stridor. Patients classically sit in a tripod position to optimize airflow. Examination of the oropharynx is often normal, but pooled oral secretions and/or edema of supraglottic structures may be seen. Although diagnosis is confirmed by visualization of an inflamed epiglottis, urgent management should be pursued to secure the airway (eg, intubation) due to risk of airway obstruction. tripod position (Choices A and D) Obesity is associated with chronic comorbidities (eg, hypertension, dyslipidemia, obstructive sleep apnea) as well as increased postoperative and nosocomial infection risk in adults. However, obesity is not associated with epiglottitis. Diabetes mellitus is associated with higher rates of epiglottitis in adults, but lack of immunization is the most significant risk factor for children. (Choice B) Inadequate dental hygiene may cause mandibular molar infections, leading to cellulitis of the submandibular space (Ludwig angina). Manifestations include fever, drooling, muffled voice, stridor, and dysphagia. However, patients typically have tender, bilateral induration of the submandibular area, often with elevation of the floor of the oropharynx (not seen in this patient). (Choice E) Secondhand smoke is associated with increased rates of childhood middle ear disease, dental caries, and lower respiratory tract infections (eg, pneumonia) but not epiglottitis. Educational objective: Epiglottitis is most commonly due to Haemophilus influenzae type b, and incompletely vaccinated individuals are at the highest risk. Manifestations include rapid onset of fever, sore throat, muffled voice, drooling, and stridor. References: Epiglottitis. (http://www.ncbi.nlm.nih.gov/pubmed/28613691)

A 4-Year-Old Boy Is Brought to the Clinic Due to Sore