Epiglottitis
Nikita Chapurin and Alexander Gelbard
N Engl J Med 2019; 381:e15
DOI: 10.1056/NEJMicm1816761
A previously healthy, fully immunized 48-year-old man presented to an urgent care clinic with a 3-day history of odynophagia, fever with temperatures of up to 40°C, and progressive shortness of breath. A lateral radiograph of the neck showed the “thumb sign” (Panel A, arrow), which was suggestive of an enlarged epiglottis. He was transferred to the emergency department, where a physical examination showed inspiratory stridor; he was sitting in the tripod position and was using accessory muscles for respiration. Immediate tracheostomy was performed while the patient was awake, and laryngoscopy revealed erythema, edema, and exudative inflammation of the epiglottis, with complete obstruction of the upper airway (Panel B). Intraoperative cultures from the epiglottis grew Streptococcus pyogenes. After 5 days of treatment with intravenous antibiotic agents targeting S. pyogenes, the tracheostomy tube was removed, and the patient was discharged home with a prescription for a 14-day course of oral amoxicillin–clavulanate. Repeat laryngoscopy 2 weeks after the initial presentation showed complete resolution of the infection (Panel C).
