NMS Q&A Family Medicine

88 NMS Q&A Family MedicineThis is recommended in monthly intramuscular injectionsin the winter months for high-risk patients. Anothermethod of prophylaxis is intravenous RSV-IG, such asRespiGam.12. The answer is D. Supportive care and supplementaloxygen are effective according to research evidence. Noneof the others are proven to be effective in hospitalizedchildren with RSV disease. Of interest is that RSV-IG,although recommended for prophylaxis, is not felt to beeffective in acute disease. Said to be “possibly effective” arenebulized ipratropium with or without a beta-2 agonist(e.g., albuterol); oral, inhaled, or parenteral glucosteroids;and nebulized epinephrine. Confounding the question ofefficacy of glucosteroids and epinephrine is that manypatients who respond may have atopic disease with anasthmatic component.13. The answer is B. Parainfluenza viruses (humanparainfluenza viruses 1, 2, and 3 account for 75% of allcases). Of interest is the fact that parainfluenza viruseshave exhibited a pattern of biennial epidemics during theautumn months of odd-numbered years since 1973.14. The answer is C. Croup, a viral illness with subglotticinvolvement, typically exhibits the symptoms of inspiratorystridor only after 12 to 24 hours of coryza, typical ofa viral “cold.” Epiglottitis, a much more serious condition,begins suddenly. Epiglottitis is caused by bacterialinfection with supraglottic involvement, classically byH . influenzae but also by S . aureus and Corynebacteriumdiphtheriae . Although epiglottitis is characterized moreby high fever than is croup, this appears to be a weakfactor on which to base a preliminary diagnosis. Whereascroup virtually always includes a cough, epiglottitis rarelydoes so. Epiglottitis typically includes dysphagia whilecroup does not. The child with croup is comfortable inall positions, whereas the patient with epiglottitis willbe sitting forward with the mouth open. Both conditionsare characterized by inspiratory dyspnea. Croup is benignand epiglottitis is potentially critical.15. The answer is E. Six months to twelve years is thewide range of age within which a child can be afflictedwith croup. In contrast, epiglottitis can affect infants, olderchildren, or adults. In adults, epiglottitis is not the potentiallylife-threatening disease as it is in younger people.16. The answer is D. The vignette describes typical epiglottitis,a respiratory emergency. Of note is the fact thatthe stridor of epiglottitis is not as dramatic as that ofcroup. Examination to confirm the diagnosis must bemade by an expert who will recognize the cherry red epiglottisand erytenoids. The antibiotic must be chosen to beeffective against H . influenzae B as well as the less frequentlyinvolved organisms Neisseria meningitidis and Streptococcusspecies. Ceftriaxone is the antibiotic of choice.ReferencesKerby GS , Deterding NR , Balasubramaniam V , et al. Respiratorytract and mediastinum. In: Hay WH , Levin MJ , SondheimerJM , Deterding RB , eds. Current Diagnosis and TreatmentPediatrics. 19th ed. New York: McGraw-Hill Lange;2007 .King MS . Respiratory diseases in infants and children . In: RudyDR , Kurowski K , eds. Family Medicine: House Officer Series .Baltimore, MD : Williams & Wilkins ; 1997 : 201 – 216 .Ostapchuk M , Roberts DM , Haddy R . Community acquiredpneumonia . Am Fam Physician . 2004 ; 70 : 899 – 908 .Steiner RWP. Treating acute bronchiolitis with RSV . Am FamPhysician. 2004 ; 69 : 325 – 330 .