Pediatrics · Year 3 · from Pediatrics
Case 1: Croup (Laryngotracheobronchitis)
Patient Demographics
- Age: 2-year-old male
- Sex: Male
Chief Complaint
"He woke up with a barking cough and noisy breathing."
History of Present Illness
A 2-year-old previously healthy male is brought to the emergency department at 2 AM by his parents. He had mild runny nose and low-grade fever (38.3C) for 2 days. Tonight, he woke up suddenly with a harsh, barking cough and noisy breathing. Parents describe the cough as sounding like a "seal barking." He is having difficulty breathing and appears scared. The symptoms seemed to worsen when he became upset and started crying. He has not had any similar episodes before. No choking episode or foreign body aspiration concerns. No recent travel or sick contacts beyond daycare.
Growth Parameters
- Weight: 13 kg (50th percentile)
- Height: 87 cm (50th percentile)
Physical Examination
- General: Anxious, mild distress, sitting upright in mother's lap, crying intermittently
- Vital signs: T 38.5C, HR 130, RR 32, SpO2 96% on room air
- HEENT:
- Mild nasal congestion, clear rhinorrhea
- Oropharynx mildly erythematous
- No drooling
- Neck: No stridor at rest; inspiratory stridor when agitated/crying
- Cardiovascular: Tachycardia, otherwise normal
- Respiratory:
- Inspiratory stridor when upset
- Barking cough
- Mild subcostal retractions
- Good air entry bilaterally
- No wheezing
- Skin: Warm, no mottling
- Neurologic: Alert, appropriate for age
Westley Croup Score
- Stridor: 1 (with agitation only)
- Retractions: 1 (mild)
- Air entry: 0 (normal)
- Cyanosis: 0 (none)
- Consciousness: 0 (normal)
- Total: 2 (mild croup)
Workup
- Clinical diagnosis - no imaging or labs required for typical presentation
- If obtained:
- Neck X-ray (AP): "Steeple sign" - subglottic narrowing (not required for diagnosis)
Diagnosis
Viral croup (acute laryngotracheobronchitis) - moderate severity
Clinical Reasoning
The classic presentation of a toddler with prodromal URI symptoms followed by sudden onset of barky "seal-like" cough, inspiratory stridor, and hoarse voice in the fall/winter is pathognomonic for croup. The age (6 months to 3 years peak incidence), timing (worse at night), and clinical features make this a clinical diagnosis. Parainfluenza virus is the most common etiology. The Westley score of 2 indicates mild croup, though the stridor with agitation suggests moderate severity requiring treatment.
Management
- Dexamethasone: 0.6 mg/kg PO x 1 dose (max 10 mg) - single dose effective for all severity
- Keep child calm: Minimize interventions that cause distress (crying worsens obstruction)
- Observation: May discharge home after observation period (typically 2-4 hours) if:
- No stridor at rest
- Good oral intake
- Normal oxygen saturation
- Reliable follow-up
- Parent education:
- Cool night air may provide temporary relief
- Return for worsening stridor at rest, increased work of breathing, drooling, or color change
- If moderate-severe (stridor at rest):
- Add nebulized racemic epinephrine 0.5 mL of 2.25% solution
- Observe for 3-4 hours after epinephrine (rebound phenomenon)
- If no improvement with treatment: Consider alternative diagnoses (bacterial tracheitis, epiglottitis, foreign body)
Clinical Image
Image Description: Anteroposterior neck radiograph demonstrating the "steeple sign" - subglottic narrowing characteristic of croup, showing the tapered tracheal air column.
Source: Radiopaedia URL: https://radiopaedia.org/cases/croup-steeple-sign-1 License: CC BY-NC-SA 3.0