What Organisms Cause Acute Epiglottitis in the Post- H. influenza Vaccination Era?

Patient Presentation
While in the resident workroom, the attending and resident overheard their Otolaryngology colleagues discussing a 3-year-old female who came into the emergency room with respiratory distress and problems swallowing, and was eventually diagnosed and treated for acute epiglottitis. Since a patient with this disease was unusual, the otolaryngology residents shared that the patient had been intubated for 36 hours and now on day 3 was doing very well and was drinking. She had been fully immunized and that to date no organism has been identified. They were planning on changing to oral antibiotics and asked the pediatric team their advice about duration of therapy. After doing a literature search and discussing the patient with the pediatric infectious disease specialist (who already knew about the patient), the team recommended a total of 10 days of therapy. The team also considered whether an immune workup was needed, but the infectious disease specialist already had a detailed history and had previously advised that it wasn’t necessary at this time.

Discussion
Epiglottitis is also known as supraglottitis and is caused by inflammation of the supraglottic structures and epiglottis. Usually the cause is infectious but other trauma such as thermal injuries or ingestions can also cause the disease. Before the widespread use of its conjugated immunization, Haemophilus influenza type b was the most common cause and it was usually thought of as a pediatric disease process. In the pre-immunization time period, acute epiglottitis in children was 3.47-6.0 cases per 100,000, and in the post-immunization period has declined to 0.3-0.7 cases per 100,000. However it appears that < 1 year old children remain at increased risk in the post-immunization time period.

Adult incidence has remained constant at 1-4 cases per 100,000. The average age range in the post-immunization period has increased to ~44 years. The adult presentation is also slightly different with odynophagia, dysphagia and voice changes being the most common signs. It may often have a slower clinical course too.

For the pediatric population, respiratory distress, dysphagia and drooling are considered the classic signs, but any symptoms of respiratory distress should alert the clinician to also consider epiglottitis in the differential diagnosis. Many of the cases of pediatric epiglottitis occur in fully immunized children. Surface and blood cultures are often negative so empiric antibiotics are usually begun.

Learning Point
Infectious causes of acute epiglottitis include:

  • Bacterial
    • Haemophilus influenzae type b and non-typeable
    • Bacteroides species
    • Kingella kingae
    • Moraxella catarrhalis
    • Streptococcus pneumoniae*
    • Streptococcus pyogenes*
    • Other Streptococcus species including agalactiae, viridins
    • Staphylococcus aureus
  • Viral
    • Epstein-Barr
    • Herpes simplex
    • Parainfluenza
    • Varicella zoster

*the most common bacterial causes in the post-immunization period currently

Questions for Further Discussion
1. How can one differentiate between acute epiglottitis, croup, bacterial tracheitis, and retropharyngeal abscess?
2. When should an immune workup be considered for a patient with a severe infectious disease?
3. What emergency management should be given for patients with acute upper airway obstruction?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Haemophilus Infections and Throat Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Briem B, Thorvardsson O, Petersen H. Acute epiglottitis in Iceland 1983-2005. Auris Nasus Larynx. 2009 Feb;36(1):46-52.

Shah RK, Stocks C. Epiglottitis in the United States: national trends, variances, prognosis, and management. Laryngoscope. 2010 Jun;120(6):1256-62.

Guardiani E, Bliss M, Harley E. Supraglottitis in the era following widespread immunization against Haemophilus influenzae type B: evolving principles in diagnosis and management. Laryngoscope. 2010 Nov;120(11):2183-8.

Derber CJ, Troy SB. Head and neck emergencies: bacterial meningitis, encephalitis, brain abscess, upper airway obstruction, and jugular septic thrombophlebitis. Med Clin North Am. 2012 Nov;96(6):1107-26.

Felter RA. Emergent Management of Pediatric Epiglottitis. Medscape.
Available from the Internet at http://emedicine.medscape.com/article/801369-overview. (rev. 07/18/2013, cited 9/3/2013).

ACGME Competencies Highlighted by Case

  • Patient Care
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    16. Learning of students and other health care professionals is facilitated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital