The Runaway Croup Train: Off the Pathway and Through the Woods

A previously healthy, fully immunized 23-month-old girl presented to the emergency department (ED) with 1 day of fever, cough, hoarseness, stridor only with agitation, and no drooling or retractions. She was given acetaminophen and dexamethasone 0.6 mg/kg orally. After these interventions, she improved and took a Popsicle. A chest radiograph and lateral neck radiograph were read as “prevertebral soft tissue thickening at the level of C5-C7, which can be seen with retropharyngeal infection versus projection or positioning.” This prompted an otolaryngology consult. Bedside flexible fiber-optic nasolaryngoscopy in the ED revealed mild to moderate swelling of the epiglottis with scattered foci of edema and erythema on the laryngeal surface of the epiglottis, mobile and moderately edematous vocal folds bilaterally, and moderate to severe subglottic stenosis, which are all findings typical of viral croup. Laboratory studies revealed a normal white blood cell count of 10.1 k/μL (reference range: 6–17.5), elevated C-reactive protein of 8.0 mg/dL (reference range: <0.9), elevated procalcitonin of 1.08 ng/mL (reference range: <0.5), and a normal chemistry. A nasal swab for respiratory pathogen polymerase chain reaction (PCR) was obtained. A diagnosis of epiglottitis was made, the patient was made NPO, maintenance intravenous fluids were started, intravenous ampicillin-sulbactam and intravenous dexamethasone were given and scheduled every 6 hours, and admission to the PICU was arranged. Three hours after admission to the PICU, the respiratory pathogen panel was reported as positive for parainfluenza virus 3, and 12 hours after admission, the patient was transferred from the ICU to the inpatient ward. The patient did not require any additional interventions in the ICU other than scheduled intravenous antibiotics and steroids. The next morning, 9 hours after transfer …