Multipathogenic necrotising supraglottitis in an immunocompetent patient

Abstract

History 38-year-old, British male, with 10 day history of upper respiratory tract infection 24 hour progressive worsening; now drooling, stridorous, with dysphonia and odynophagia Examination Primary survey: Biphasic stridor, tachypnoea, tachycardia, pyrexial, normotensive Neck examination: Tender laryngeal skeleton Intra-oral examination: Palatal and oropharyngeal erythema and oedema Fibroptic nasendoscopy (FoNE): Epiglottic erythema and oedema, left-sided laryngopharyngeal swelling with significant airway compromise Initial treatment Benzylpenicillin; Metronidazole; Dexamethasone; analgesia; IV fluids Awake fibroptic-intubation in theatres; 3 days in level 3 care setting Ward treatment Cefuroxime; Metronidazole; Oseltamivir (guided by throat swab cultures) Cultures indicated heavy growth of Group A β-haemolytic streptococcus and Influenza A virus Microbiology guidance lead to Benzylpenicillin and Oseltamivir At which point the patient began to decline Repeat FoNE revealed epiglottic slough; this coalesced and ulcerated over the next 24 hours Acute symptoms returned CT scan (Images 1-4) Reported as left-sided parapharyngeal abscess and laryngeal abscess Epiglottis Hyoid Vocal cords Sagittal mid-line section Procedure Tracheostomy formation. Incision and drainage (attempt). Debridement. Findings at microlaryngoscopy: (Images 5-7) Membranous necrotic slough over left hemi-larynx extending to right false cord; no pus was found. The debrided tissue sample was sent for microscopy, culture and sensitivities. Microbiological analysis reveled growth of Enterococcus faecalis sensitive to the final course of treatment; Ceftriaxone, Clindamycin and Metronidazole. Histology revelaed necrotic tissue composed of fibrin and inflammatory cell infiltrate; indicative of a necrotising inflammatory process (Images 8 and 9).Low-power microscopy High-power microscopyPost-operatively the patient went to level 3 care for a further 2 days after which he was transferred to the ward and made a complete recovery.