Case Presentation: A 2-month-old male, born at 32 weeks, presented with nasal congestion, fever and respiratory distress requiring supplemental oxygen. Mother reported that he was hospitalized for bronchiolitis 2 weeks ago and was discharged home on oxygen. On admission CBC, CMP, UA, CSF studies, blood and urine culture were all normal. Chest X-Ray was consistent with viral illness. However on the 6th day of hospitalization he developed acute stridor, appeared dusky and there was noted difficulty passing a 5F catheter. Echo was notable for small Patent Foramen Ovale. Chest MRA reported an aberrant right subclavian artery but no vascular rings. New born screen, urine organic acids and plasma amino acids were reported as normal. Bedside fiberoptic examination reported patent bilateral nares but edema of supraglottic structures as well as a subglottic lesion. Microlaryngoscopy/Bronchoscopy (MLB) confirmed the lesion to be a left sided subglottic hemangioma (SGH). Propranolol 1 mg/kg/day was initiated. He remained hospitalized for 4 more days with gradual improvement and was discharged home.

Discussion: Our differential diagnoses included airway abnormalities like laryngomalacia, choanal atresia, vascular rings or any mass obstructing the airway, other congenital heart defects and inborn errors of metabolism. After extensive work-up came back normal; an MLB revealed a left sided SGH. SGH is a benign tumor of infancy, usually present at birth and becomes symptomatic during the first 1-3 months of life. Inspiratory stridor is common, and they are often misdiagnosed as croup. Overall, infantile hemangiomas occur in 4-5% of Caucasian infants. In pediatric airway, these growths account for 1.5% of congenital abnormalities. The natural history is characterized by an initial rapid proliferation of the blood vessels leading to progressive obstruction of airway followed by gradual regression of the vascular component. They are diagnosed on MLB. Treatment includes oral propranolol 1 mg/kg/day with weekly increments of 1 mg/kg to a total of 3 mg/kg/day. Vital signs and blood glucose should be monitored for 24 hours with every increase in dose. Our patient was admitted for weekly increments to monitor his vital signs and blood glucose. He remained on Propranolol for 4 months and no further intervention was needed. He continued to follow up with ENT and PCP as needed.

Conclusions: Physicians should have a high index of suspicion for SGH in infants presenting with stridor. Early diagnosis and treatment is very essential in proliferative phase of the tumor particularly because of its location in the airway. This case posed a challenge for our team because of lack of stridor on initial presentation. A viral illness superimposed on infantile SGH may bring it sooner to medical attention but may also delay a diagnostic procedure and ultimate diagnosis.