Shortness of breath, inspiratory stridor, drooling, and fever. Immunizations are up to date.
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AP and lateral views of the neck were performed. The AP view shows narrowing of the upper airway, and mild, diffuse small airway inflammatory changes within the lung apices. On the lateral view, the classic "thumbprint sign" is seen, characterized by indistinct thickening of the epiglottis, reflecting edema and inflammation.
Epiglottitis is inflammatory thickening and edema of the epiglottis and aryepiglottic folds which can acutely compromise the airway, especially in young children. Haemophilus influenza type B (Hib), is the common causative organism; however, group A beta-hemolytic Streptococcus is becoming more common, especially amongst those vaccinated for Hib. It is most commonly seen in young children, ages 3-6. Prompt recognition allows for expeditious treatment, to include airway management, steroids, and antibiotics.
The differential in this case included laryngotracheobronchitis (croup), given the narrowing of the upper airway on the frontal view, but the degree of narrowing was not felt to quite constitute the designation of "steepling". Furthermore, after discussion with the ordering ER physician, the patient's clinical picture better matched that of epiglottitis. Appropriate measures were taken to ensure stability of the child's airway and he was started on antibiotics, steroids and IV fluids.
- Grover C. Images in clinical medicine. "Thumb sign" of epiglottitis. N. Engl. J. Med. 2011;365 (5): 447. doi:10.1056/NEJMicm1009990