A Retrospective Cohort Study of Acute Epiglottitis in Adults

Introduction: Adult epiglottitis is a disease process distinct from pediatric epiglottitis in microbiology, presentation, and clinical course. While traditionally considered more indolent and benign than in children, adult epiglottitis remains a cause of acute airway compromise with a mortality rate from 1-20%. Our objective was to characterize the disease course and evaluate the rate and type of airway management in this population at a tertiary, academic referral center. Methods: We conducted a retrospective chart review of all adult patients (age ≥ 18) who were definitively diagnosed with infectious “epiglottitis,” “supraglottitis,” or “epiglottic abscess” by direct or indirect laryngoscopy during a nine-year period. Double data abstraction and a standardized data collection form were used to assess patient demographic characteristics, presenting features, and clinical course. The primary outcome was airway intervention by intubation, cricothyroidotomy, or tracheostomy, and the secondary outcome was mortality related to the disease. Results: Seventy patients met inclusion criteria. The mean age was 50.2 years (standard deviation ± 16.7), 60% of the patients were male, and 14.3% were diabetic. Fifty percent had symptoms that were present for ≥ 48 hours; 38.6% had voice changes, 13.1% had stridor, 12.9% had fever, 45.7% had odynophagia, and 47.1% had dysphagia noted in the ED. Twelve patients (17.1%) received an acute airway intervention including three who underwent emergent cricothyroidotomy, and one who had a tracheostomy. Two patients died and one suffered anoxic brain injury related to complications following difficult airway management. Conclusion: In this case series the majority of patients (82.9%) did not require airway intervention, but a third of those requiring intervention (5.7% of total) had a surgical airway performed with two deaths and one anoxic brain injury. Clinicians must remain vigilant to identify signs of impending airway compromise in acute adult epiglottitis and be familiar with difficult and failed airway algorithms to prevent morbidity and mortality in these patients.

143. Use of First-Generation Cephalosporins in Patients with Serious Penicillin Allergies

Background Penicillin allergies have a negative impact on patient outcomes due to utilization of second-line agents. Newer data suggests cephalosporins are well tolerated in penicillin allergies; however, none have solely evaluated anaphylactic penicillin allergies with first-generation cephalosporins. The purpose of this study was to evaluate the risk of any allergic reaction to first-generation cephalosporins compared to aztreonam in patients reporting anaphylaxis to an agent in the penicillin class. Methods This was a retrospective cohort study with patients who reported “anaphylaxis” to a penicillin agent and received cefazolin, cephalexin, or aztreonam. The final analysis included 220 patients: aztreonam (n=81), cefazolin (n=81), and cephalexin (n=58) (Figure 1). IgE-mediated reactions (within six hours of antibiotic administration) were defined as any one of the following: anaphylaxis, angioedema, urticarial rash, hypotension, immediate airway compromise, or receipt of epinephrine, hydrocortisone, or diphenhydramine. Non-IgE mediated reactions (within thirty days of antibiotic administration) included delayed hypersensitivity reactions and other dermatologic reactions. Figure 1: Patient Enrollment Patients admitted between January 1, 2013 to September 1, 2020 with a reported allergy of “anaphylaxis” to an agent in the penicillin class who received at least one dose of cefazolin, cephalexin, or aztreonam were screened for inclusion. Patients were excluded if the allergy was deleted from the electronic health record prior to antibiotic administration. All first-generation cephalosporin patients were included. Aztreonam patients were included in chronological order and limited to the number of included cefazolin patients. Results There were less allergic reactions in the first-generation cephalosporin group compared to the aztreonam group, but this was not statistically significant (7% vs. 14%, p=0.077). There were fewer IgE-mediated reactions in the cephalosporin group (6% vs. 14%, p=0.046). No difference in allergic reactions was observed when comparing those who received a single antibiotic dose versus multiple doses within the cephalosporin and aztreonam groups, respectively (3% vs. 11%, p=0.082, 20% vs. 12%, p=0.451). Because cephalexin has a similar R1 side chain to aminopenicillins, five patients with an aminopenicillin allergy who received cephalexin were evaluated separately; none had an allergic reaction (Table 1, Table 2, Figure 2). Table 1: Baseline Characteristics The median age was higher in the aztreonam group, and the majority of patients were female and Caucasian. There were significantly more pregnant females in the cephalosporin group, and the majority of patients reported a natural penicillin allergy. Table 2: Outcomes There were less allergic reactions (IgE or non-IgE mediated) in the first-generation cephalosporin group compared to the aztreonam group, but this was not statistically significant. Also, there were fewer IgE-mediated reactions in the cephalosporin group. There was no difference in allergic reactions in patients with two or more reported drug allergies compared to less than two drug allergies. No difference in allergic reactions was observed when comparing those who received a single antibiotic dose versus multiple doses within the cephalosporin and aztreonam groups. Of the five patients who received cephalexin and reported an aminopenicillin anaphylactic allergy, none had an allergic reaction. Additionally, there were not any patients readmitted within 30 days for delayed hypersensitivity reactions and no antibiotics were discontinued due to other documented adverse reactions. Figure 2: Occurrence of Allergic Reactions Of the patients who had allergic reactions in the cephalosporin and aztreonam groups, these included immediate airway compromise, hypotension with one patient in the aztreonam group receiving vasopressors within the pre-defined time frame, receipt of the non-standing rescue medication of diphenhydramine, and drug rash. Conclusion There was no difference in the incidence of allergic reactions between the aztreonam and first-generation cephalosporin group, and fewer serious allergic reactions occurred in the cephalosporin group. This study suggests that cefazolin and cephalexin can safely be used in patients who report anaphylaxis to an agent in the penicillin class. Disclosures Janessa Smith, PharmD, Merck & Co. (Employee)

SURGICAL MANAGEMENT OF A MASSIVE CONGENITAL HEMANGIOMA OF THE TONGUE IN AN INFANT: A RARE CASE REPORT

Lesions involving the tongue may present with life threatening complications such as airway compromise and risk of severe hemorrhage. This paper reports the surgical management of a non-involuting massive congenital hemangioma of the tongue in an infant presenting with difficulty breathing, feeding and inability to close the mouth.

Trigeminal Zoster with drug-induced labial angioedema leading to necrosis

Introduction. Zoster is caused by the reactivation of a dormant viral infection, and is characterized by painful, vesicular lesions along a dermatome. Neuritic pain associated with zoster can be treated with anticonvulsant medications. Case Report. An immunocompetent adult physician developed prominent zoster lesions in the trigeminal nerve distribution. Treatment included antiviral therapy for the acute infection, and pharmacotherapy for neuritic pain. Pharmacotherapy included several anticonvulsant agents, with labial angioedema developing after initiation of oxcarbazepine. Discussion. The case is notable for the pictorial timeline of lesion development, as well as the marked incident angioedema following initiation of treatment for neuritis with oxcarbazepine. Conclusions. Clinicians should remain vigilant for drug-induced facial angioedema when treating patients with trigeminal zoster-related neuritis due to the potential for angioedema to aggravate a lesion, resulting in scarring. Angioedema of the head and neck should be closely monitored due to the potential for airway compromise.

Undiagnosed pharyngeal perforation following a penetrating neck trauma in a 5-year-old child: a proposed treatment algorithm

External penetrating wounds of the neck leading to pharyngeal perforations are relatively uncommon. The small area of the neck contains the vital vascular, aerodigestive and nervous structures, which are difficult to access surgically. Pharyngeal perforations are challenging to treat, especially in children, as primary wound inspection may be difficult, leading to life-threatening complications like retropharyngeal abscesses, mediastinitis or airway compromise. The following is a case report of a 5-year-old girl who had a road traffic accident causing a neck laceration with a pharyngeal tear, which was only identified during emergency neck exploration in the operating room. A review of known literature and a proposed algorithm for managing penetrating neck injuries with pharyngeal injury is described.