WIDI - P5) Stridor and fever in an infant

P5) Stridor and fever in an infant

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with stridor.
Review the DDx considerations in stridor.
Identify the spectrum of imaging findings in appropriate modalities for evaluating patients with stridor.

History

A 1-year-old female is brought to the ED by her parents due to a one-day history of high fever, sore throat, noisy breathing, and excessive drooling. The parents note that the symptoms have become increasingly severe over the past few hours. Of note, the parents have elected for an unspecified modified vaccine schedule for their daughter.

Physical Exam

BP: 86/42, HR 150, RR 42, Temp 39.2C, O2 saturation 90%. General: Ill-appearing child in moderate distress sitting in a forward-leaning position with a hyperextended neck. The patient has a muffled voice. HEENT: Pooling of oral secretions. Respiratory: There is inspiratory stridor.

Labs

None.

Provisional Diagnosis

Select the Dx you believe is most appropriate

Croup

Epiglottitis

Foreign body

Angioedema

This patient most likely has acute epiglottitis based on the presentation of an acute febrile illness, sore throat, and respiratory distress with inspiratory (supraglottic) stridor, drooling, and tripod positioning in the context of a modified vaccination schedule.

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

The patient with a tenuous airway requires emergent workup and intervention.

First Imaging Study

What is the first imaging study you will order?

Neck CT

Neck MRI

Neck X-ray

Neck ultrasound

A soft-tissue lateral neck x-ray is the best initial imaging modality to evaluate for epiglottitis. The imaging is quick to obtain and relatively sensitive for an enlarged protruding epiglottis (“thumb sign”).

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Soft-tissue lateral neck x-ray

The subglottic airway demonstrates pathological narrowing.

Yes

The subglottic airway is normally patent. Subglottic narrowing is a feature of croup.

The size of the epiglottis is abnormally increased.

Yes

The free edge of the epiglottis is thickened and is as wide as it is tall.

View Report

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Second Imaging Study

What is the next imaging study you will order?

Neck CT

Neck MRI

Neck ultrasound

None

No further imaging is needed as the diagnosis is confirmed on the plain films.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Croup

Epiglottitis

Foreign body aspiration

Based on the physical exam disclosing pharyngeal erythema, an enlarged epiglottis, drooling and stridor, along with imaging which demonstrates the “thumb sign” this patient is experiencing respiratory distress secondary to epiglottitis.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

The patient is demonstrating signs and symptoms of impending airway obstruction requiring emergent management.

Assessment and Plan

Please provide your assessment and plan for this patient

This patient is a 1-year-old female presenting with acute epiglottitis. The primary focus in such patients is airway management. The presence of signs of impending airway obstruction including stridor, drooling, and tripod posturing should prompt emergent intubation. Following airway management, empiric antimicrobial therapy should be initiated.

Lessons Learned:
- Younger children (<5) are more likely to present with respiratory distress due to acute Epiglottitis.
- H. influenzae type b (Hib) is a common etiology of epiglottitis, particularly among unimmunized individuals.
- Epiglottitis can progress rapidly to life-threatening airway obstruction, thus airway management should be a primary focus of this presentation.
- While plain films of the neck are a diagnostic tool in the evaluation of epiglottitis, in the setting of acute respiratory distress they are not necessary as direct visualization during airway management is sufficiently diagnostic.

Socioeconomic Factors: There has been a decreased incidence in pediatric cases associated with H. influenzas infections (i.e., Epiglottitis) due to the launch of Hib vaccination programs in the US and other countries.

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Contributors:
Jordan Turetsky, MS4 - Content Contributor
Khalida Clark - Content Contributor
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator