A 46–year–old woman presented with a 4 day history of progressive throat pain and low grade fever. She went to an urgent care clinic 3 days prior to admission and was discharged on ibubrofen and amoxicillin. A lateral view X–ray of the neck reveals findings consistent with acute epiglottitis. A flexible larygoscopic examination done showed a large partially obstructing edematous epiglottis. Her WBC count was 20,700. She was admitted to the ICU and was started on intravenous ampicillin/sulbactam. She stayed in the ICU for the next 36 h with no acute events such as airway compromise that needed emergent intervention. Eventually, she was transferred to the medical/surgical floor and was discharged after 3 days of hospitalization. She was sent home with oral amoxicillin/clavulanic acid and prednisone. The next day she had an ENT outpatient follow up where her epiglottitis was assessed to be worsening. She was sent back to the emergency room right away due to difficulty breathing and increasing right sided facial swelling. An emergency tracheostomy was done. Repeat larygoscopy revealed a thickened epiglottis with ulceration and fibrinopurulent discharge. The arytenoids were markedly edematous and the laryngeal inlet was completely obstructed. Intravenous ampicillin/sulbactam and vancomycin were initiated. She was readmitted to the ICU. The tissue cultures came back positive for MRSA and Enterobacter cloacae. Intravenous ampicillin was discontinued and replaced with intravenous piperacillin/tazobactam . CT scan of the head and neck showed a 3.3 cm abscess posterior to the right submandibular gland. Incision and drainage was done and cultures of the abscess was also positive for MRSA. Additional history revealed that she had a dental procedure a week before her first hospitalization. She eventually improved and was discharged after 11 hospital days.
The annual incidence of acute epiglottitis in adults appears to be increasing. When an etiologic agent is identified, it is usually Hemophilus influenzae. Other bacteria including Streptococcus pneumonia, Staphylococcus aureus (both methicillin sensitive and resistant strains) and Beta–hemolytic streptococci are among the more common causes of bacterial epiglottitis. Mortality rates in adults are less than 3.3% and death is almost always caused by an acute airway obstruction. This case illustrates the danger of missing out on the etiologic agent of acute epiglottitis. On the initial admission, the patient was not treated for MRSA and was readmitted for worsening upper airway obstruction that needed emergent tracheostomy. She also had an extension of the infection to the parapharygeal tissues causing an abscess that needed drainage.
Patients with acute epiglottitis need to be empirically treated for MRSA until cultures results come back.
Figure 1Green arrow points to the enlarged and inflammed epiglottis.
Figure 2Area pointed by green arrow indicates severely inflammed epiglottis.