Fulminant meningococcal supraglottitis: An emerging infectious syndrome?

We report a case of fulminant supraglottitis with dramatic external cervical swelling due to associated cellulitis. Blood cultures were positive for Neisseria meningitidis. The patient recovered completely after emergency fiberoptic intubation and appropriate antibiotic therapy. We summarize five other cases of meningococcal supraglottitis, all reported since 1995, and discuss possible pathophysiologic mechanisms.

Adult epiglottitis: the Toronto Hospital experience

OBJECTIVE

This study was conducted to gain insight into the diagnosis, treatment, and outcome measures in adult patients presenting with acute epiglottitis.

METHOD

A retrospective clinical study was conducted on fifty-seven consecutive adult patients presenting with acute epiglottitis over a 13-year period to The Toronto Hospital, University of Toronto. Demographic description of patient population, presenting symptoms and signs, investigations performed, treatment provided, and incidence of complications were described.

RESULTS

Soft-tissue lateral neck x-rays were abnormal in 88.1% of patients tested but had a 12% false-negative rate. Indirect, direct, or flexible laryngoscopy were the most accurate investigations to establish diagnosis and were not associated with any complications. Four of 45 patients (8.9%) had positive blood cultures for Haemophilus influenzae, with the remainder demonstrating no growth, while 22% of patients (8/36) grew possible pathogenic organisms on throat culture. A rapid clinical course (< 12 hr), evidence of tachycardia, or positive pharyngeal or blood cultures were factors that selected for a group of patients requiring formal airway intervention.

CONCLUSIONS

Adult epiglottitis is different from its paediatric counterpart in that organism identification is less common, the clinical course is more gradual, there is less seasonal variation, airway compromise is more uncommon, and conservative airway management can be contemplated in the selected patient. Adult epiglottitis can be managed safely with a selective approach to airway management with airway intervention for any patient with signs of critical airway compromise.

Acute meningococcal epiglottitis and septicaemia in a 65-y-old man

We report a case of acute meningococcal epiglottitis in a 65-y-old man. He was noted to have stridor of acute onset. We highlight the importance of the diagnosis of acute epiglottitis, early establishment of an airway and appropriate antibiotic therapy. This case report mainly concerns the association of unusual pathogen Neisseria meningitidis and adult acute epiglottitis.

Aetiology of acute epiglottitis in adults

In order to determine the aetiology of acute epiglottitis in adults, blood cultures, paired sera and a urine sample were obtained from 54 patients with fever and epiglottitis visualized by indirect laryngoscopy or by direct fibreoptic nasolaryngoscopy. Antibodies were determined against the capsular polysaccharide of Haemophilus influenzae type b (Hib), 3 pneumococcal antigens (a mixture of 23 capsular polysaccharides, C-polysaccharide and pneumolysin) and antistreptolysin O. Acute sera were examined by the polymerase chain reaction (PCR) for DNA of Hib and pneumococci. The urine samples were examined for Hib capsular antigen. Blood cultures were positive in 15 patients. In another 16, serology and/or PCR verified the aetiology. Hib was the cause in 14, pneumococci in 12 and group A streptococci in 5 patients. The aetiology remained unknown in 23/54 patients (43%). In conclusion, the addition of serology and PCR to blood cultures doubled the possibilities of verifying the aetiology of acute epiglottitis in adults.

[Acute epiglottitis caused by Haemophilus influenzae type b in children: presentation of 21 cases]

BACKGROUND

The aim of this paper is to review the epidemiological, clinical and therapeutical characteristics of Haemophilus influenzae type b (Hib) epiglottitis in children at a time when an efficient and safe vaccination is available.

METHODS

The clinical histories of 21 children admitted to Children's Hospital La Fe (1971-1996) with a clinical diagnosis of epiglottitis and isolation of the microorganism in blood cultures (20 cases) and surface culture of the epiglotis (one case) are reviewed.

RESULTS

The annual average was 4/100,000 children under 5 years of age. Evolution prior to diagnosis was > 12 hours in 52.4% of the cases. More males were affected (52.4% vs 47.6%). All the children except one (95.2%) were under 5 years of age; 81% were under 3 years of age and 1 child was 6 years and 8 months old. Respiratory distress (100%) and fever > or = 38 degrees C (85.7%) were the most common clinical manifestations. General health was affected in 71.4% of the cases and 66.7% had leucocytosis on admission. The clinical diagnosis was confirmed by direct visualization of the epiglotis in 76.1% of the cases. Hib was isolated in blood culture in 20 cases (95.2%). The strains produced beta-lactamases and were ampicillin-resistant in 57.1%. 19 children (90.5%) required endotracheal intubation. Initial empiric antibiotic therapy was third generation cephalosporins (cefotaxime or ceftriaxone) alone or combined with ampicillin. One child died (4.8%).

CONCLUSIONS

Pediatricians must still be aware of this serious infection in order to diagnosis and treat it as early as possible.

Pasteurella multocida epiglottitis

Pasteurella multocida, a small gram-negative coccobacillus, colonizes the nasopharynx and gastrointestinal tract of many animals, including cats and dogs. Most human infections with P multocida are due to animal bites, but the respiratory tract is the second most common site of infection. We describe the third case report (to out knowledge) of acute P multocida epiglottitis. The mode of transmission in this case was inhalation of infectious nasopharyngeal secretions from cats. The patient responded well to treatment with penicillin, the drug of choice for P multocida infections. Therefore, infection with P multocida, though rare, should be considered in the differential diagnosis in any case involving acute epiglottitis and exposure to cats.

[Serious streptococcal infections of the head and neck region]

This article describes the four cases of serious infections caused by Streptococcus pyogenes in the head and neck. Three patients presented with invasive infections of the soft tissues in the neck and one with epiglottitis. Two patients fulfilled the criteria for toxic streptococcal shock syndrome. The incidence of severe streptococcal disease is increasing in Norway, which emphasizes the importance of an aggressive attitude when diagnosing and treating atypical throat infections.

[Acute epiglottitis in the adult]

Epiglottitis is a well-defined syndrome caused by Haemophilus influenzae type B in children. It also may affect adults and has an unpredictable clinical course, sometimes complicated with airway obstruction. Two cases of adult epiglottitis are reported. The first responded favorably to medical treatment and the second required emergency airway surgery. Indicators of poor prognosis are described. Epiglottitis should be considered in the differential diagnosis as a potentially lethal cause of sore throat.