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Key Features

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  • Also called pseudomembranous croup

  • Severe life-threatening form of laryngotracheobronchitis

  • Staphylococcus aureus most common isolated organism

  • Other organisms that have been reported include

    • Haemophilus influenza

    • Group A Streptococcus pyogenes

    • Neisseria species

    • Moraxella catarrhalis

  • A viral prodrome is common

  • Disease probably represents localized mucosal invasion of bacteria in patients with primary viral croup, resulting in inflammatory edema, purulent secretions, and pseudomembranes

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Clinical Findings

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  • Early clinical picture is similar to that of viral croup

  • However, instead of gradual improvement, symptoms worsen

    • Higher fever

    • Toxicity

    • Progressive or intermittent severe upper airway obstruction that is unresponsive to standard croup therapy

  • Incidence of sudden respiratory arrest or progressive respiratory failure is high, requiring airway intervention

  • Findings of toxic shock and the acute respiratory distress syndrome may also be seen

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Diagnosis

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  • White blood cell count is usually elevated with a left shift

  • Cultures of tracheal secretions usually demonstrate one of the causative organisms

  • Blood cultures are almost always negative

  • Lateral neck radiographs show a normal epiglottis but severe subglottic and tracheal narrowing

  • Irregularity of the contour of the proximal tracheal mucosa can frequently be seen radiographically and should elicit concern for tracheitis

  • Bronchoscopy showing a normal epiglottis and the presence of copious purulent tracheal secretions and membranes confirms the diagnosis

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Treatment

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  • Direct visualization of the airway in a controlled environment and debridement of the airway is required

  • Most patients will be intubated because the incidence of respiratory arrest or progressive respiratory failure is high

  • Patients may also require further debridement, humidification, frequent suctioning, and intensive care monitoring to prevent endotracheal tube obstruction by purulent tracheal secretions

  • Intravenous antibiotics to cover S aureus, H influenzae, and the other organisms are indicated

  • Despite the severity of this illness, the reported mortality rate is very low if it is recognized and treated promptly

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