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A 2-year-old boy presents to the emergency department (ED) with cough for 2 days. His mother describes the cough as barky, almost seal-like. Mom reports that the cough was preceded by a couple of days of runny nose. He is not ill appearing and currently does not have a fever. What is the most common cause of the patient's symptoms?

A. Staphylococcus aureus

B. Respiratory syncytial virus (RSV)

C. Haemophilus influenzae type b

D. Parainfluenza virus (PIV)

E. Adenovirus

Answer: D

The patient has infectious croup (laryngotracheobronchitis); PIV is the most common cause of infectious croup in young children. There are 4 serotypes, with PIV-3 being the most prevalent. Other viruses may be involved less commonly, including RSV and adenovirus. With croup, PIV causes inflammation, edema, and necrosis of epithelium of the subglottic tissues. This results in the classic "barky" cough; the cough is usually preceded by a few days of rhinorrhea and nasal congestion. In more severe cases, stridor, nasal flaring, and suprasternal or subcostal retractions may be observed. Corticosteroids are the mainstay of therapy, reducing severity and duration of symptoms.

S aureus is associated with bacterial tracheitis. With bacterial tracheitis, patients present with high fever and are ill appearing. Tracheoscopy usually demonstrates large amounts of mucopurulent secretions and subglottic edema, along with tracheal sloughing.

Now rarely seen due to widespread routine immunization, H influenzae type b was a common cause of epiglottitis, a life-threatening emergency due to inflammation and swelling of the epiglottis. In contrast to croup, patients appear severely ill, with fever, stridor, drooling, and often a "tripod" appearance (leaning forward and extending the neck to open the airway and increase air entry).

A 3-year-old girl, who was previously healthy, presents to your clinic with a 3-day history of fever (maximum temperature of 103°F) and wet-sounding cough. On exam, she is tachypneic, with a respiratory rate of 32 breaths/min; no retractions are seen, and you note crackles on the right anterior chest. Pulse oximetry reveals oxygen saturation of 94% on room air. A chest radiograph (CXR) confirms a right middle lobe infiltrate. What is the best first-line treatment option for this patient?

A. Oral azithromycin

B. Intravenous (IV) ceftriaxone

C. Oral amoxicillin

D. Oral ciprofloxacin

E. Supportive care (no antibiotics)

Answer: C


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