key: cord-0755918-cj7uskn0
authors: Zuccarelli, AM; Leonard, CG; Hampton, SM
title: LARYNGOTRACHEOBRONCHITIS, CROUP, AN UNUSUAL PRESENTATION OF SARS-COV-2
date: 2022-02-11
journal: Ulster Med J
DOI: nan
sha: 9a8a666139f04ffc02ede8a403cac52e7332f60a
doc_id: 755918
cord_uid: cj7uskn0

nan

From the outset we maintained a broad differential. Given the presenting features, stroke, encephalomeningitis and Covid-19 infection were at the forefront of our differential. She was empirically treated with IV acyclovir, ceftriaxone and dexamethasone while awaiting results of lumbar puncture. Following diagnosis she continued on acyclovir alone. This patient gradually recovered with no residual symptoms although she reported retrograde amnesia of her initial presentation. Follow up MRI showed a resolving process.

Herpes Simplex virus (HSV) is responsible for 19% of cases of infectious encephalitis. [1] It represents significant morbidity and mortality to patients with a one year mortality rate of 14%. [2] Typically, patients present with symptoms of fever, headache and confusion although speech disturbance can be seen in 57% and focal neurological deficit in 26% of cases. [3] Encephalitis is a known mimic of stroke and atypical presentations can often be misdiagnosed. In some cases this has led to inappropriate treatment with alteplase and in others misdiagnosis can lead to delay in initiating appropriate treatment. [4] The emergence of Covid-19 has further confounded this area. Neurological manifestations of Covid-19 can been seen in up to 25% of patients. [5] On MRI, unilateral medial temporal lobe oedema, a recognised finding in HSV encephalitis, has been demonstrated in patients with Covid-19 in the absence of HSV.

[6] This overlap in features risk delay in initiation of correct treatment for patients.

We feel this case is of particular interest as it highlights the importance of maintaining an open mind when managing a patient who has an atypical combination of symptoms particularly in the context of the current pandemic. 4 

Laryngotracheobronchitis or croup, whilst common in childhood, is rare in adults. We present an unusual clinical presentation of infection with Sars-COV-2, COVID-19 Laryngotracheobronchitis.

A 52-year-old female presented to the Emergency Department with a three day history of progressive fatigue, hoarseness and dysphagia. On examination she was sitting forward, breathing quietly, aphonic and drooling. She had mild bilateral cervical lymphandenopathy. Flexible nasendoscopy showed mild supraglottic oedema and erythema, but no airway compromise. Chest xray demonstrated "steeple sign" (Figure 1) indicative of laryngotracheobronchitis or "croup."

She had a mild inflammatory response demonstrated by a corticosteroids to reduce airway oedema. Following 24 hours the patient improved clinically, and flexible nasoendoscopy revealed resolution of supraglottic oedema. The patient was discharged with a five day course of oral dexamethasone.

Laryngotracheobronchitis, commonly referred to as croup, is an upper respiratory tract infection, almost exclusively seen in the paediatric population. It commonly presents with fever, "barking" cough, stridor, dyspnoea, and hoarseness. Adult croup is more severe than in the paediatric cohort, and often requires aggressive treatment and longer hospital stays 1 . Direct evidence of oedema, and the typical "steeple sign" feature on x-ray, which represents subglottic narrowing, is more commonly found in adults 1 It is deemed the most serious of skin cancers due to its propensity to metastasise widely, which can affect all organ systems including the gastrointestinal tract (GIT). We present three cases of metastatic melanoma who presented with gastrointestinal (GI) symptoms within a three month period to a tertiary centre.

A 72 year old man had a previous history of cutaneous melanoma, treated with wide local excision, three years prior to the current presentation. He presented with melaena, symptomatic anaemia and abnormalities of his small bowel were noted on CT abdomen. Upper GI endoscopy identified multiple small black tumour deposits ( Figure 1A ). Follow up MR enterography confirmed several small bowel lesions which were suspicious for metastatic disease. He subsequently developed small bowel obstruction secondary to intussusception and proceeded to have a small bowel resection. Three separate tumours were removed and histology confirmed metastatic melanoma.

A 66 year old man was referred to the GI outpatient service with symptomatic anaemia, intermittent change in bowel habit and weight loss. CT imaging identified an abnormal gallbladder mass. Subsequent MRI confirmed a 5.6cm mass arising from the gallbladder. Following laparotomy this was identified as a malignant melanoma. Whereas primary gallbladder mucosal melanomas have been reported they are extremely rare, and a metastasis was considered more likely.

A 75 year old man gave a history of melanoma removed by wide local excision from his anterior abdominal wall 15 years previously. He presented to the Emergency Department with melaena and iron deficiency anaemia was noted. Upper GI endoscopy was normal. CT imaging revealed thickening at the duodeno-jejunal junction. At enteroscopy an ulcerated tumour Figure 1A Multiple small black deposits of metastatic melanoma in the gastric mucosa at endoscopy (Patient 1)

UK Health Protection Agency (HPA) Aetiology of Encephalitis Study Group, et al. Causes of encephalitis and differences in their clinical presentations in England: a multicentre, population-based prospective study

Herpes simplex encephalitis in Sweden

Herpes simplex virus encephalitis: clinical manifestations, diagnosis and outcome in 106 adult patients

A narrowing diagnosis: a rare cause of adult croup and literature review. Case Rep Crit Care

Croup: an overview

Pediatric croup with COVID-19

A curious case of croup: laryngotracheitis caused by COVID-19

Appearance and management of COVID-19 laryngo-tracheitis: two case reports