Case 2: Persistent Stridor After Upper Respiratory Tract Infection in a 2-month-old Boy.

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1. Alice Walz, MD* 2. Veena Goel, MD† 3. Juliann Kim, MD† 1. *Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN. 2. †Lucile Packard Children’s Hospital at Stanford, Palo Alto, CA. A 6-week-old boy who was born at 36 weeks’ gestation is brought to his family physician because he has experienced 1 week of “noisy breathing” after resolution of his first cold. Based on inspiratory stridor in the otherwise well child, the physician recommends supportive care and close follow-up evaluation. The infant’s symptoms persist for another week, and he is brought to urgent care for evaluation of difficulty in breathing. On physical examination, the child is afebrile and has a heart rate of 157 beats/min, respiratory rate of 40 breaths/min, and oxygen saturation of 98% in room air. His weight is 5.08 kg, which is at the 32nd percentile. He has both inspiratory and expiratory stridor, a barky cough, and abdominal retractions. Otolaryngology urgently assesses him in the office, and bedside flexible laryngoscopy reveals only mild upper airway edema. Because of concern that his stridor is due to residual inflammation from his recent upper respiratory tract infection or reflux, the otolaryngologist prescribes oral prednisone and omeprazole. The following day the infant’s retractions and respiratory distress are worse, prompting evaluation in the emergency department. After finding nothing of note on chest radiography and no improvement after three doses of inhaled racemic epinephrine and dexamethasone, he is admitted for further observation and management of suspected …