Snapshot A 9-year-old boy is brought to the emergency department by his mother. She reports that he has had a low grade fever and some mild difficulty breathing over the past 2 days. His fever spiked this afternoon and he seems to be in greater respiratory distress. An AP film shows subglottic narrowing. The is no improvement with racemic epinephrine. Gross pathology of the disease in a beef heifer is shown. Introduction Bacterial superinfection caused by Staphylococcus aureas or Strep spp. Caused by long-standing, often untreated, primary viral upper respiratory infection (croup) caused by parainfluenza virus Epidemiology occurs in ages 3 months to 2 years old often a complication of croup Presentation Symptoms prodrome upper respiratory infection usually lasts 2-3 days high fever inspiratory stridor (less often than in primary croup) followed by acute decompensation usually occurs over period of 10 hours until respiratory failure and death Physical exam severe respiratory distress Evaluation Neck radiograph show subglottic narrowing (similar to croup) Labs elevated leukocytes Differential Croup, epiglottitis, inhaled foreign body, retropharyngeal abscess, angioedema Treatment Medical management hospitalization and supportive therapy guided by degree of respiratory distress may require supplemental O2, nebulizers, and/or steroids no response to racemic epinephrine IV antibiotics nafcillin ceftriaxone Prognosis, Prevention, and Complications Prognosis average to good, depending on timing of diagnosis and aggressiveness of treatment Prevention proactive medical management of croup and other upper respiratory infections Complications respiratory decompensation can be fatal