Bacterial croup and toxic shock syndrome

An 8-year-old boy with bacterial tracheitis, treated by endotracheal intubation, humidification, airway toilet and antibiotics, experienced a toxic shock syndrome on the day after his admission. The course was favourable. Staphylococcus aureus was isolated from tracheal secretions. Bacterial tracheitis is an infrequent cause of non-menstrual toxic shock syndrome. The diagnosis of bacterial tracheitis should be suspected in a child with toxicity and croup who is not responding to the usual therapy. Endoscopy should be performed allowing for removal of the secretions. The maintenance of a clear airway is the main purpose of the treatment.Abbreviations TSS toxic shock syndrome - CNS central nervous system - CRP C-reactive protein - ICU intensive care unit     

Laryngitis revealing bacterial tracheitis in a five-year-old child]

CASE REPORT: We report the case of a five-year-old boy with clinical features of croup and left lower lobe pneumonia. Response to inhaled adrenaline and dexamethasone was incomplete and he developed respiratory distress. Direct laryngoscopy performed in the operating room showed mild glottic and subglottic inflammation. On bronchoscopy, there was thick pus coming from the left lower lobe. He was intubated for three days and regular toilet brought back thick pus. Tracheal fluid culture grew Haemophilius influenzae. COMMENTS: We suggest that he had bacterial tracheitis but that the tracheal involvement was not prominent at the time of diagnosis. CONCLUSION: Laryngoscopy and bronchoscopy in specialized surroundings should be considered for each child with croup unresponsive to conventional treatment, especially in case of lower respiratory tract involvement.     

Severe upper airway obstruction in the tropics requiring intensive care

BACKGROUND: The clinical profile of severe upper airway obstruction, a challenging acute pediatric emergency, has not been extensively documented in the developing nations of the tropics. METHODS: The diagnostic categories, severity of illness and outcome from 63 episodes of severe upper airway obstruction in 56 children admitted to the Pediatric Intensive Care Unit between January 1994 and December 1999 were reviewed. Outcome variables studied included requirement for ventilation, mortality and complications. Severity of illness was determined with the Pediatric Risk of Mortality (PRISM) II score. RESULTS: Viral croup (29%) was the most common diagnosis, followed by mediastinal malignancy (13%), bacterial tracheitis (11%) and Pierre Robin syndrome (11%). There were no admissions for acute epiglottitis. Thirty episodes (48%) required ventilation for a median duration of 4.0 days. Bacterial tracheitis (100%) and subglottic stenosis (100%) were the most likely diagnoses requiring ventilation. Difficulty in intubation was encountered in 13 episodes (43%) involving, in particular, patients with bacterial tracheitis (83%; P = 0.006). Only two patients required a tracheostomy. The overall mortality was 11%. The PRISM score for all categories was generally low (mean 10.3 +/- 1.0; median 9.0). Non-survivors had a significantly higher PRISM II score than survivors (27.4 +/- 9.7 vs 8.1 +/- 4.9, respectively; P = 0.002) and were more likely to include children with bacterial tracheitis and mediastinal malignancy. CONCLUSIONS: There is marked heterogeneity in the causes of upper airway obstruction in the tropics with viral croup remaining the most common. A significant proportion required ventilation, but outcome is generally favorable, except in those with bacterial tracheitis and mediastinal malignancy.     

Bacterial tracheitis in pediatrics: 12 year experience at a medical center in Taiwan

Background:  Bacterial tracheitis may cause life-threatening airway obstruction.
Methods:  Records of patients admitted to the pediatric wards of Mackay Memorial Hospital between 1994 and 2005 with a diagnosis of bacterial tracheitis made on bronchoscopic visualization of thick membranous tracheal secretions were retrospectively reviewed.
Results:  A total of 40 patients (aged 1 month–8 years, 29 [73%] under 3 years old) were included. Cough, fever, dyspnea, and hoarseness were the commonest symptoms. Fourteen patients (21%) required intubation. The most frequently isolated bacteriae were α-hemolytic streptococcus (in 11, 38%), pseudomonas (5, 17%), and Staphylococcus aureus (4, 14%). Intubation was more frequent in patients seen between 1994 and 1999 compared with those seen later (8/12 early vs 9/28 late). In the early period α-hemolytic streptococcus (55%) and pseudomonas (36%) were isolated. In the later period the most frequently isolated bacteria was α-hemolytic streptococcus (28%), followed by S. aureus (22%). No patients died, but those with pseudomonas infection had more severe complications, including tracheal stenosis. The average hospital stay in the early period was 26.2 ± 20.5 days versus 9.1 ± 4.8 days in the late period. The corresponding lengths of stay in the intensive care unit were 10.5 ± 11.5 days and 2.0 ± 2.2 days.
Conclusions:  Bacterial tracheitis requiring hospitalization of children appeared to be milder in the second half of the study period. Pseudomonas tracheitis tends to have a severe course.     

Bacterial tracheitis caused by Corynebacterium diphtheriae

Diphtheria has become a rare disease in Germany. We report on an unimmunized 3.5-year-old German girl with a 7-day history of respiratory distress and fever, presenting a clinical picture mimicking typical bacterial tracheitis without pharyngeal and laryngeal manifestation. Diagnosis of diphtheria was not made until culture of tracheal secretions yielded growth of a toxigenic strain of Corynebacterium diphtheriae. The patient died from toxic cardiac failure despite treatment with diphtheria antitoxin. This is the second reported case of isolated bacterial tracheitis caused by Corynebacterium diphtheriae. Conclusion The observation of a lethal course of diphtheric tracheitis emphasizes the paramount im-portance of immunization against diseases like diph-theria. Received: 4 July 1996 / Accepted: 24 September 1996     

Acute upper airway obstruction

Acute upper airway obstruction continues to challenge medical practitioners who care for children. Whilst usually straightforward, management can be complicated by incorrect diagnosis, unexpected deterioration, difficulty in assessing the need for intubation, difficulty in providing optimal intubation skills and confusion over the value of various therapies.The highest priority is preventing death or hypoxic injury in those few children who progress to profound obstruction.In this overview, the term laryngotracheitis is used as a synonym for croup and laryngotracheobronchitis, epiglottitis is used as a synonym for supraglottitis, and bacterial tracheitis is used as a synonym for pseudomembranous croup. The term ‘intubation’ is used as an abbreviation for mechanical relief of airway obstruction.     

The outcome of patients with upper airway obstruction transported to a regional paediatric intensive care unit

The diagnoses, transfer, management and outcome of patients with upper airway obstruction (UAO) admitted from district general hospitals (DGH) to a regional paediatric intensive care unit were retrospectively reviewed over a 3.5-year period. Sixty-seven patient episodes were analysed. Fifty-two cases (78%) underwent tracheal intubation prior to transport with a low morbidity for both procedures. The most common diagnosis was viral croup (n= 34, 51%) with a median duration of intubation of 5 days, with subglottic stenosis being the next most common category (n= 10, 15%), median duration of intubation 7 days. Inhaled budesonide was used prior to intubation in 12 (35%) of those with croup, and inhaled bronchodilators in 28%, possibly reflecting diagnostic uncertainty. Patients with croup treated with budesonide were significantly less likely to require intubation (P= 0.04). The re-intubation rate for patients with viral croup was uncomfortably high at 16% (4/25) despite the routine use of prednisolone throughout the intubation period. Successful extubation of patients with viral croup could not be predicted by age (P= 0.31), length of intubation (P= 0.94), endotracheal tube size, (P= 0.60) abnormalities on the chest X-ray (P= 1.0), or presence of secondary bacterial infection (P= 0.23). Conclusion Although viral croup remains the most common diagnostic category presenting at the DGH level with severe UAO, a wide range of other diagnoses is seen. Despite clear evidence of benefit, steroid administration to children presenting at the DGH with viral croup has not become routine practice. Once intubated, no reliable predictors of successful extubation were found amongst this patient group. Received: 10 November 1997 / Accepted: 2 March 1998     

Bacterial tracheitis in children: Approach to diagnosis and treatment

Bacterial tracheitis is due to a secondary bacterial infection of the trachea, resulting in the formation of mucopurulent exudates that may acutely obstruct the upper airway, resulting in a life-threatening condition. Bacterial tracheitis should be considered in the differential diagnosis of any child with acute upper airway obstruction. This diagnosis should also be considered in any child with viral croup that is nonresponsive to conventional therapy. The only definitive way to diagnose bacterial tracheitis is by direct visualization of the trachea via bronchoscopy; however, this may not be required in all cases. Management includes close observation and monitoring, early initiation of broad spectrum antibiotics, pain management and aggressive airway clearance techniques. The decision to intubate should be individualized based on the severity of symptoms, age of child and accessibility of personnel skilled at emergency intubation techniques. If diagnosed and treated early, complete recovery is expected.     

Acute Upper Airway Obstruction

Upper airway obstruction is defined as blockage of any portion of the airway above the thoracic inlet. Stridor, suprasternal retractions, and change of voice are the sentinel signs of upper airway obstruction. Most of the common causes among children presenting to emergency department are of acute infectious etiology. Among these, croup is the commonest while diphteria remains the most serious life-threatening cause. Recent reports indicate that bacterial tracheitis has become increasingly common. In ER evaluation the key clinical data in determining the cause and the site of obstruction are the onset, presence of fever, character of the stridor, retractions, the voice and the ability to handle secretions. After assessment of the severity of respiratory distress and resuscitative or supportive therapy including oxygen and emergent airway, specific treatment is directed at underlying etiology. All patients with audible stridor require early endotracheal intubation/tracheostomy. In croup the mainstay of treatment are cold humidified oxygen, budesonide nebulization ( in mild cases), Dexamethasone 0.6 mg/kg iv or im (in moderate and severe cases), and Adrenaline 5 ml 1:1000 (5 mg) solution as nebulization ( in severe cases). In diphtheria, early tracheostomy, anti-diphtheric serum and injectable penicillin are critical. Bacterial Tracheitis and Retropharyngeal abscess need early administration of injectable Cloxacillin, Amikacin and Clindamycin. ENT consultation should be obtained for early surgical drainage of retropharyngeal abscess. Angioneurotic edema is treated with subcutaneous adrenaline (1:1000, 0.01 ml/kg); hydrocortisone 10 mg/kg IV and antihistamines. Patients with severe obstruction and those with endotracheal tube/ trachesotomy should be transferred to PICU.     

Respiratorische Notf?lle im Kindes- und Jugendalter

Dyspnoea, inspiratory stridor, wheeze, cyanosis and chest pain are common symptoms of respiratory emergencies in children and adolescents. The airways of infants and toddlers are narrow and soft and oxygen reserve is small. Muscle fatigue can quickly lead to respiratory insufficiency. Symptoms, diagnosis, differential diagnosis and therapy of foreign body inhalation, croup, epiglottitis, bacterial tracheitis, bronchiolitis and acute asthma are dealt with in detail.     

Can early bacterial complications of aspiration with respiratory failure be predicted?

We studied the early infectious complications of all children admitted for intensive care over a six-year period who were at high risk of having severe aspiration of gastric or pharyngeal secretions. Patients were only analyzed if they required mechanical ventilation for acute respiratory failure, had a blood culture obtained in the first 48 hours, and survived at least 24 hours. Infections were identified by positive blood cultures. Possible infections were defined as fever (over 38.5 degrees C), abnormal leukocyte count (greater than 10,000 or less than 5000), and a potential pathogen in tracheal secretions. Patients' diagnoses included near-drowning (13), aspirated foreign body (5), observed aspiration of gastric contents in a hospitalized patient (2), and hydrocarbon aspiration (1). Of 21 high-risk patients, five (23.8%) had infections and two (9.5%) had possible infections in the first 48 hours. In contrast, no late infections were seen. Infected patients tended to be older (P less than 0.05). No diagnostic features in the first two days of hospitalization reliably identified those who would develop early infections (P greater than 0.05). Since early life-threatening infection is common and cannot be reliably predicted by clinical signs, we recommend aggressive bacteriologic surveillance and the administration of IV antibiotics on admission to all patients in respiratory failure requiring mechanical ventilation after presumed aspiration of gastric or pharyngeal secretions.     

Pseudomembranous croup.

During a 2-year period, 7 children were seen with a severe form of laryngotracheobronchitis associated with sloughing of the respiratory epithelium and profuse mucopurulent secretions. We have called this condition pseudomembranous croup. The children had severe upper airways obstruction, appeared toxic with high fever, and were older than the typical age group for viral laryngotracheobronchitis. Lateral x-ray films of the airways showed subglottic narrowing and often these suggested the presence of radio-opaque foreign material in the tracheal lumen. At endoscopy, in addition to pseudomembrane in the subglottic region and trachea, there was thick mucopus and debris, and in some cases these changes extended into the bronchi. An artificial airway was required in all except one, and even after intubation it proved difficult to maintain the airway. Staphylococcus aureus was the most common pathogen isolated from tracheal cultures but other organisms were grown.     

Bacterial croup caused by Pasteurella haemolytica

Abstract We report a case of bacterial croup caused by Pasteurella haemolytica. A nine-month-old girl was admitted to our hosptial because of abrupt onset dyspnea and unconsciousness. From clinical and laboratory findings, she was diagnosed as having bacterial croup. Pasteurella haemolytica was recovered from her tracheal secretion on admission. To our knowledge, this is the first report of bacterial croup caused by P. haemolytica.     

Role of parainfluenza virus-specific IgE in pathogenesis of croup and wheezing subsequent to infection

In order to determine the role of parainfluenza virus-specific IgE antibody production and release of histamine in the pathogenesis of lower respiratory disease caused by parainfluenza virus infection, we studied 84 infants and children at the time of parainfluenza virus infection. Parainfluenza virus-IgE antibody was detected in samples of nasopharyngeal secretions by means of an enzyme-linked immunosorbent assay, and histamine content of nasopharyngeal secretions was determined by a fluorometric technique. Virus-specific IgE responses appeared earlier and were of greater magnitude in patients with croup, wheezing, and croup with wheezing caused by parainfluenza virus infection than in patients with parainfluenza virus-induced upper respiratory illness. Histamine was detectable in nasopharyngeal secretions of patients with parainfluenza virus-related croup significantly more often than in patients with upper respiratory illness caused by parainfluenza virus. These observations suggest a role for immunologic mechanisms in the pathogenesis of severe forms of respiratory illness caused by parainfluenza virus infection.     

Systemic complications associated with bacterial tracheitis.

The toxic shock syndrome, septic shock, pulmonary oedema, and the acute respiratory distress syndrome (ARDS) were recognised in four children with bacterial tracheitis. ARDS has not previously been reported in association with bacterial tracheitis. Prompt recognition of the severe systemic complications of bacterial tracheitis could lead to a decrease in the morbidity and mortality of this condition.     

Viral croup: a current perspective

Viral croup is the most common cause of upper airway obstruction in children 6 months to 6 years of age. Parainfluenza virus accounts for the majority of cases. The disease is characterized by varying degrees of inspiratory stridor, barking cough, and hoarseness because of laryngeal and/or tracheal obstruction. The diagnosis is mainly a clinical one and diagnostic studies usually are not necessary. The management has altered dramatically in the past decade. Good evidence exists to support the routine use of corticosteroid in all children with croup. Intervention at an earlier phase of the illness will reduce the severity of the symptoms and the rates of return to a health care practitioner for additional medical attention, visits to the emergency department, and admission to the hospital. Most children respond to a single, oral dose of dexamethasone. For those who do not tolerate the oral preparation, nebulized budesonide or intramuscular dexamethasone are reasonable alternatives. Nebulized epinephrine should be reserved for patients with moderate to severe croup. Simultaneous administration of corticosteroid and epinephrine reduces the rate of intubation in patients with severe croup and impending respiratory failure.     

Acquired subglottic stenosis caused by methicillin resistant Staphylococcus aureus that produce epidermal cell differentiation inhibitor

Local infection of the trachea in intubated neonates is one of the main risk factors for development of acquired subglottic stenosis, although its role in the pathogenesis is unclear. Methicillin resistant Staphylococcus aureus (MRSA) is often the cause of critical illness in neonatal patients. Two cases are reported of acquired subglottic stenosis following bacterial infection of the trachea, suggesting an association with the staphylococcal exotoxin, epidermal cell differentiation inhibitor (EDIN). EDIN-producing MRSA were isolated from purulent tracheal secretions from both infants. Acquired subglottic stenosis in both cases was probably caused by delayed wound healing as the result of EDIN inhibition of epithelial cell migration.     

Double blind placebo controlled trial of nebulised budesonide for croup

AIMS: To determine whether nebulised budesonide improves the symptoms or shortens the duration of stay of children admitted to hospital with a clinical diagnosis of croup. METHODS: A prospective, randomised, double blind placebo controlled trial. Patients received either nebulised budesonide or placebo every 12 hours. The main outcome measures were duration of inpatient stay and croup scores at 30 minutes, one, two, four, 12, and 24 hours. RESULTS: 87 patients (89 admissions) aged 7-116 months entered the trial. Nebulised budesonide was associated with a significant improvement in symptoms at 12 hours (95% confidence interval (CI) 1 to 3) and 24 hours (95% CI 0 to 3). Patients with an initial croup score above 3 demonstrated a significant improvement in symptoms at two hours (95% CI 1 to 3). Nebulised budesonide was also associated with a 33% reduction in the length of stay (95% CI 2% to 63%) when the confounding variables of age, initial croup score, and coryzal symptoms were taken into consideration. CONCLUSIONS: Nebulised budesonide is an effective treatment for children admitted to hospital with a clinical diagnosis of croup.     

From clinical practice to guidelines: how to recognize rhinosinusitis in children

Rhinosinusitis is a common childhood respiratory infection. Children have approximately six to eight viral infections of the upper respiratory tract each year, 5–13% of which may be complicated by a secondary bacterial infection of the paranasal sinuses. The diagnosis of acute bacterial rhinosinusitis in children is established by the persistence of purulent nasal or post-nasal draining lasting at least 10 days, especially if accompanied by supporting symptoms and signs, at which point antibiotic treatment has to be recommended. Appropriate antibacterial therapy should also be recommended if the draining has been present for less time, but is concomitantly associated with significant fever and localized signs of sinus inflammation in a child who appears ill. Imaging studies are not necessary to confirm the diagnosis of clinical rhinosinusitis for the purposes of treatment, but should be reserved for cases in which the diagnosis is in doubt or a complication is suspected, and for patients with recurrent or chronic rhinosinusitis. Under these circumstances, computed tomography is the preferred evaluation. Together with their clinical judgment, these suggestions may be useful for pediatricians in diagnosing this common condition.     

儿童迁延性细菌性支气管炎临床诊治的研究进展

迁延性细菌性支气管炎(protracted bacterial bronchitis,PBB)是儿童慢性咳嗽的常见原因之一.PBB的特征是持续湿性咳嗽>4周,除外其他原因的慢性湿性咳嗽,连续2周的抗生素治疗有效.支气管镜检查和支气管肺泡灌洗可发现支气管炎和支气管内脓性分泌物,支气管肺泡灌洗液标本通常显示显著的中性粒细胞浸润并可培养出大量呼吸道病原体,特别是流感嗜血杆菌.此病的病理生理机制现在尚未完全明确.