Epiglottitis :: etiology
Department of Anaesthesia, St George's Hospital, London, UK.
Most cited papers:
Candida seldom has been reported to be a cause of epiglottitis. The clinical manifestations and management of three patients with Candida epiglottitis complicating their neoplastic disease are described. All patients were granulocytopenic. Candida epiglottitis occurred either as a localized infection, as a source of Candida bronchopneumonia, or as a manifestation of disseminated infection. Candida epiglottitis may be under-diagnosed and should be considered, especially in immunocompromised patients with symptoms of refractory pharyngitis. Treatment of Candida epiglottitis with intravenous amphotericin B is warranted in patients with sustained granulocytopenia. Prompt endotracheal intubation is indicated if the airway patency cannot be maintained.
Incidence, predisposing factors and manifestations of invasive Haemophilus influenzae infections in adults.
A retrospective study was conducted on invasive Haemophilus influenzae infections in adults (greater than or equal to 16 years) for the period 1971-1983 in two regions in Sweden. The annual incidence was determined to be 1.1 per 100,000. Predisposing factors included advanced age, bronchopulmonary diseases, alcoholism, traumatic head injury, malignant diseases and pregnancy. Pleuropulmonary infections were the most common manifestations followed by epiglottitis, meningitis and septicaemia of unknown origin. A death rate of 8% was established. Both encapsulated and non-typable strains were found to be potentially pathogenic, but the non-typable strains had a lower virulence.
Comparison of the epidemiology and cost of Haemophilus influenzae type b disease in five western countries.
D A Clements, R Booy, R Dagan, G L Gilbert, E R Moxon, M P Slack, A Takala, H P Zimmermann, P L Zuber, J Eskola
Department of Pediatrics, Duke University Medical Center, Durham, NC 27710.
To determine and compare the cost of Haemophilus influenzae type b (Hib) disease in Australia, Finland, Israel, Switzerland and the United Kingdom a collaborative study was undertaken. The incidence of Hib disease varies in these 5 countries from 34 to 58.5 cases per 100,000 children less than 5 years of age. Although the incidence of meningitis in this age group is similar (between 18 and 26/100,000) in these countries, the incidence of epiglottitis varies from 0 to 22.7/100,000. The cost of hospitalization and the frequency of sequelae are similar for 4 of the 5 countries; however, the break even cost of a vaccination program to prevent 90% of Hib disease is estimated to vary from $22 to $84 per child (US$). Because of a lower incidence of Hib disease and lower cost for hospitalization, these costs are considerably less than those for the United States ($301.64 using similar calculations).
Haemophilus influenzae type b strains of outer membrane subtypes 1 and 1c cause different types of invasive disease.
Of 275 consecutive Haemophilus influenzae type b (Hib) strains isolated from children with invasive disease in Finland in 1985-86, 74% were of the common European outer membrane protein (OMP) subtype 1 and 22% were of OMP subtype 1c, which is usually rare. Strains of subtype 1c caused proportionately more meningitis and less epiglottis than did strains of subtype 1c. Furthermore, children with disease due to strains of subtype 1c were younger than those with disease due to strains of subtype 1. The significant difference in association between subtype and the diagnosis of epiglottitis or meningitis remained even when the strong influence of age was accounted for. This finding may suggest a true difference in the virulence between these subtypes not previously demonstrated for Haemophilus influenzae type b.
We treated four adults whose upper airway was compromised due to acute epiglottitis. We also reviewed the English literature for all reports of this condition in adults (18 years and older). Among the 158 cases, the infectious etiology was identified in 29 (H. influenzae 20, Streptococcus pneumoniae six, H. parainfluenzae two, Streptococcus pyogenes one). In the remaining cases, the etiology was uncertain. Bacteremia was documented in 23/32 patients (71.9%), but extra-epiglottic infections were strikingly rare (X = six). The clinical manifestations were sore throat (100%), fever (88%), dyspnea (78%), dysphagia (76%), anterior neck cellulitis or tenderness (27%), hoarseness (21%), pharyngitis (20%) and anterior cervical lymphadenopathy (9%). Complete airway obstruction ensued in 23 out of the 119 subjects (18.3%) who had respiratory difficulty. Overall mortality rate was 17.6% but it was 6.4% among the patients who were semi-electively tracheostomized or endotracheally intubated. These findings illustrate that antibiotics therapy active against H. influenzae is required in the treatment of acute epiglottitis in adults. Additionally, airway patency should be established when inspiratory stridor appears assuring uncomplicated recovery.
Department of Otology and Laryngology, Massachusetts Eye and Ear Infirmary, Boston.
Epiglottitis in pediatric patients is an infection caused by Haemophilus influenzae type b, which can lead rapidly to sepsis and an asphyxial death. In an effort to study the cause and clinical course of adult epiglottitis, eight serially hospitalized adult patients with supraglottitis over a ten-month period were prospectively evaluated, including a daily laryngeal examination. Although multiple anatomic sites in the larynx and oropharynx were inflamed, the epiglottis was often not the most involved area and was actually normal in one patient. Bacterial cultures were harvested from blood, the nasopharynx, the oropharynx, and the vallecula in all patients and the preepiglottic space in two patients. In no case was H influenzae demonstrated. No patient developed respiratory compromise. It was concluded that epiglottitis is an inaccurate description of this disorder and that this non-H influenzae adult variety of supraglottitis seemingly can follow a less pernicious course than the classically described infection.
A 40-year-old white woman presented with fever, otalgia, and odynophagia and was found to have a peripheral white blood cell count of 90,000/mm3. A diagnosis of acute myelogenous leukemia was made. Further evaluation of symptoms and source for fever led to the diagnosis of Candida albicans epiglottitis. This is the first reported case of fungal epiglottitis in an immunocompromised adult.
Department of Paediatrics, Mölndal Hospital, Sweden.
A retrospective study of the incidence, aetiology and case fatality rate of acute epiglottitis in children and adults was performed. The study covered the whole of Sweden (population 8.4 million) during the years 1987-89, before general vaccination against Haemophilus influenzae (Hi) type b was started. Patients were included if it was documented that they fulfilled all 3 of the following criteria:(a) red and swollen epiglottis visualized by indirect laryngoscopy,(b) inspiratory stridor or difficulties in swallowing, and (c) a temperature > or = 38 degrees C. A total of 306 children and adolescents (0-19 years) and 502 adults (> or = 20 years) were found. The age-specific incidence was highest in children aged 0-4 years,(14.7/100,000 per year). The total incidence was 3.2/100,000 per year. In the age group 0-19 years, blood cultures had been obtained from 195 (64%) and Hi was isolated from 154 (79%). In adults (> or = 20 years), 114 of 298 blood cultures yielded Hi, while pneumococci were isolated from 5 and group A streptococci from 3 patients. A total of 220 children (72%) and 114 adults (23%) needed an artificial airway. Five children and 12 adults died. In conclusion, the incidence of acute epiglottis in Sweden is very high. Compared to a previous country-wide study covering the years 1981-83 that used the same methods for case finding and case definition, the incidence in children had decreased while the incidence in adults had increased.
Modern medical oncology has made dramatic improvements in the prognosis of many malignancies. Many of the treatment regimens used by the chemotherapist have the potential to profoundly depress the immune system. At UCLA Medical Center, three patients developed epiglottitis secondary to the fungus Candida albicans, while profoundly immunocompromised. All three had severe pain and odynophagia. The patients were all managed medically and none went on to airway obstruction. The natural history of this process is reviewed.
University of Western Ontario, Department of Otolaryngology, London, Canada.
All cases of epiglottitis admitted to the three affiliated teaching hospitals of the University of Western Ontario over the ten year period prior to December 1986, were subjected to a retrospective chart review. The findings confirmed the suspicion of the senior authors that adult epiglottitis is almost as frequent an entity as epiglottitis in children. This probably results from an increased awareness of the disease process rather than an actual increase in incidence. Also of note is the bimodal age distribution of 0-8 years in children and 20-40 years in adults. As well, clinical presentation, causative organisms, treatment modalities and complications between adults and pediatric age groups are compared and contrasted.