Q 1:
An 18-month-old girl is brought to the emergency department by her mother, who reports that
the girl has had a high fever and difficulty breathing for 1 day. She has had a barking cough for
the last 3 days but had been afebrile and breathing comfortably until today. Her immunizations
are up to date. Her temperature is 104ºF (40°C), her respiratory rate is 50 breaths/min, she
exhibits inspiratory stridor and a brassy cough, and she appears ill. Lung examination reveals
decreased breath sounds bilaterally with transmitted upper airway sounds. An anterior neck
radiograph shows subglottic narrowing and a ragged tracheal air column.
Of the following, the MOST likely diagnosis is
A. acute viral laryngotracheitis
B. angioneurotic edema
C. bacterial tracheitis
D. epiglottitis
E. retropharyngeal abscess
Answer
C
Bacterial tracheitis is a serious infection causing significant upper airway obstruction. It typically
occurs as a secondary staphylococcal infection following viral laryngotracheobronchitis, but it
also may develop as a primary infection without preceding symptoms of croup. Clinical features
include a toxic appearance, with high fever, tachypnea, and brassy cough, as described for the
girl in the vignette. Airway obstruction can be pronounced due to purulent airway secretions, and
lower airway disease such as wheezes or rales also may be present. Neck radiographs often
reveal a ragged air column or subglottic narrowing, and peripheral white blood cell counts
frequently are elevated. Treatment consists of intravenous antibiotics and airway control.
Endotracheal intubation frequently is required until the infection is treated and the severity of
secretions improves.
Acute viral laryngotracheitis typically causes a barking cough with occasional inspiratory
stridor, but affected children usually do not have high fevers or appear ill.
Angioneurotic edema is a response to histamine release with an allergic reaction and often is accompanied by
urticaria. Upper respiratory tract mucosae become edematous, so inspiratory stridor may be
present, but fever is unlikely.
Children who have epiglottitis appear toxic and have significant airway compromise and inspiratory stridor due to the swollen epiglottis. Cough is rare. Lateral neck radiograph reveals an enlarged epiglottis (“thumb sign”) rather than a ragged air column.
Further, epiglottitis is unlikely in a child whose immunizations are up to date. A retropharyngeal abscess can develop with pharyngitis, and inspiratory stridor and respiratory distress with high fever is typical. The lateral neck radiograph reveals widening of the prevertebral tissues, and computed tomography scan of the neck can confirm the presence of the abscess.
----
Q 2:
A 2-year-old boy has had a purulent drainage from the right nostril for a week. He is afebrile and has had no associated symptoms, such as cough. Which of the following is the most likely diagnosis?
(A) sinusitis
(B) nasal polyps
(C) an upper respiratory infection
(D) a foreign body in the right nostril
(E) allergic rhinitis
Answer :
(D)
Children frequently insert foreign bodies into the nose. Initial symptoms are local obstruction, sneezing, and pain. Subsequently, there is swelling and infection leading to a purulent, malodorous, and often bloody discharge.
The infection clears after removal of the foreign body. Nasal polyps cause obstruction of the nasal passages, hyponasal speech, and mouth breathing; gray, grape-like masses can be visualized on nasal examination. An
upper respiratory infection is usually suggested by a careful history. Initial symptoms include a scratchy throat, followed by development
of thin nasal discharge and sneezing. Myalgia, low-grade fever, headache,malaise, and decreased appetite may be present. By the 2nd or 3rd day, the discharge becomes thicker and more purulent. Cough is common. Symptoms usually resolve by 7–10 days. Adolescents with sinusitis may have classic
symptoms of headache and sinus tenderness.
In children, cough and nasal discharge arecommon; the cough is worse when supine. If upper respiratory infection symptoms persist without improvement for >10 days, sinusitis should be considered. A more acute form may occur, with a shorter duration and more severe symptoms such as fever >39°C, purulent nasal
discharge, headache, and eye swelling. Children with allergic rhinitis present with sneezing,
clear watery, rhinorrhea, and itching of the nose, palate, pharynx, and eyes. Itching, redness, and
tearing of the eyes may be present. This occurs in response to exposure to an allergen such as pollen, mold spores, and animal or mite antigens.
Answer
C
Bacterial tracheitis is a serious infection causing significant upper airway obstruction. It typically
occurs as a secondary staphylococcal infection following viral laryngotracheobronchitis, but it
also may develop as a primary infection without preceding symptoms of croup. Clinical features
include a toxic appearance, with high fever, tachypnea, and brassy cough, as described for the
girl in the vignette. Airway obstruction can be pronounced due to purulent airway secretions, and
lower airway disease such as wheezes or rales also may be present. Neck radiographs often
reveal a ragged air column or subglottic narrowing, and peripheral white blood cell counts
frequently are elevated. Treatment consists of intravenous antibiotics and airway control.
Endotracheal intubation frequently is required until the infection is treated and the severity of
secretions improves.
Acute viral laryngotracheitis typically causes a barking cough with occasional inspiratory
stridor, but affected children usually do not have high fevers or appear ill.
Angioneurotic edema is a response to histamine release with an allergic reaction and often is accompanied by
urticaria. Upper respiratory tract mucosae become edematous, so inspiratory stridor may be
present, but fever is unlikely.
Children who have epiglottitis appear toxic and have significant airway compromise and inspiratory stridor due to the swollen epiglottis. Cough is rare. Lateral neck radiograph reveals an enlarged epiglottis (“thumb sign”) rather than a ragged air column.
Further, epiglottitis is unlikely in a child whose immunizations are up to date. A retropharyngeal abscess can develop with pharyngitis, and inspiratory stridor and respiratory distress with high fever is typical. The lateral neck radiograph reveals widening of the prevertebral tissues, and computed tomography scan of the neck can confirm the presence of the abscess.
----
Q 2:
A 2-year-old boy has had a purulent drainage from the right nostril for a week. He is afebrile and has had no associated symptoms, such as cough. Which of the following is the most likely diagnosis?
(A) sinusitis
(B) nasal polyps
(C) an upper respiratory infection
(D) a foreign body in the right nostril
(E) allergic rhinitis
Answer :
(D)
Children frequently insert foreign bodies into the nose. Initial symptoms are local obstruction, sneezing, and pain. Subsequently, there is swelling and infection leading to a purulent, malodorous, and often bloody discharge.
The infection clears after removal of the foreign body. Nasal polyps cause obstruction of the nasal passages, hyponasal speech, and mouth breathing; gray, grape-like masses can be visualized on nasal examination. An
upper respiratory infection is usually suggested by a careful history. Initial symptoms include a scratchy throat, followed by development
of thin nasal discharge and sneezing. Myalgia, low-grade fever, headache,malaise, and decreased appetite may be present. By the 2nd or 3rd day, the discharge becomes thicker and more purulent. Cough is common. Symptoms usually resolve by 7–10 days. Adolescents with sinusitis may have classic
symptoms of headache and sinus tenderness.
In children, cough and nasal discharge arecommon; the cough is worse when supine. If upper respiratory infection symptoms persist without improvement for >10 days, sinusitis should be considered. A more acute form may occur, with a shorter duration and more severe symptoms such as fever >39°C, purulent nasal
discharge, headache, and eye swelling. Children with allergic rhinitis present with sneezing,
clear watery, rhinorrhea, and itching of the nose, palate, pharynx, and eyes. Itching, redness, and
tearing of the eyes may be present. This occurs in response to exposure to an allergen such as pollen, mold spores, and animal or mite antigens.
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