Management Dilemma: A Case of Acute Epiglottitis Secondary to Group A Streptococcus (GAS)

Abstract

SESSION TITLE: Shock SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: In adults, epiglottitis has a male preponderance with the potential for rapid airway obstruction. Risk factors include hypertension, diabetes mellitus (T2DM), substance abuse and immune deficiency. CASE PRESENTATION: A 52-year-old male with history of T2DM, obesity and alcohol abuse presented with shortness of breath and choking sensation. Intubation was attempted in the ER for respiratory distress using a size 6 endotracheal tube. Chest X-ray revealed poor tube position despite multiple attempts to advance it. Epinephrine and pulse steroids were administered. Emergent bronchoscopy showed swelling of the supraglottis and an emergent tracheostomy was performed. Labs revealed leukocytosis with bandemia. Neck CT scan confirmed acute epiglottitis with critical airway stenosis. Bronchoalveolar lavage and blood cultures grew GAS. Bacteremia cleared two days after admission with Ceftriaxone and Vancomycin. Patient had spiking fevers and was noted to be extremely agitated. He received steroids for five days after a second CT neck revealed no interval change in edema.(Image 2) Two weeks after persistent fevers and hemodynamic instability requiring pressors, antibiotics were switched to Penicillin (PCN) G and Clindamycin without resuming steroids. After 24 hours, patient had significant clinical improvement and was subsequently weaned off the ventilator. He was seen in the clinic after discharge with complete resolution of symptoms. DISCUSSION: Multiple retrospective studies have noted that epiglottitis in adults can be managed conservatively with airway support required in only 6.6 - 16% of patients. We encountered a severe case of acute epiglottitis in an adult male who failed to respond clinically after two weeks of appropriate antibiotic coverage and a trial of steroids but responded to the addition of Clindamycin. The loss of penicillin binding proteins in ‘stationary growth phase’ bacteria occurs in more invasive streptococcal infections rendering PCNs less effective. Clindamycin suppresses bacterial toxin production, enhances opsonization, decreases cytokine activation and has a post-antibiotic effect.1 A recent in-vivo and in-vitro study endorsed the addition of Clindamycin to PCN in severe streptococcal infections.2 CONCLUSIONS: GAS epiglottitis can present in adults with risk factors: male sex, diabetics and substance abuse. With poor clinical response, complications such as toxic shock syndrome should be considered. The addition of Clindamycin to PCN in severe streptococcal infections may be beneficial with its action on slow growing bacteria and ability to inhibit bacterial toxin production. Reference #1: 1.Russell NE, Pachorek RE. Clindamycin in the treatment of streptococcal and staphylococcal toxic shock syndromes. Ann Pharmacother. 2000;34(7-8):936-939. Reference #2: 2.Andreoni F, Zürcher C, Tarnutzer A, et al. Clindamycin Affects Group A Streptococcus Virulence Factors and Improves Clinical Outcome. J Infect Dis. 2016;1:jiw229. DISCLOSURE: The following authors have nothing to disclose: Hisham Hakeem, Marnie Aguasvivas, Lokesh Dayal, Killol Patel No Product/Research Disclosure Information