On examination, the patient did not have stridor, but she did emit upper airway noise from secretions in her oropharynx. A white plaque was observed on the patient's soft palate. Her white blood cell count was less than 0.1 K/[micro]1.
The patient was taken to the operating room for telescopic laryngoscopy, bronchoscopy, and bronchoalveolar lavage. On laryngoscopy, profuse white plaques were seen covering the entire epiglottis and supraglottic structures with extension down to the glottis (figure). The epiglottis was both erythematous and edematous, but it did not obstruct the glottic inlet. Cultures and a biopsy were taken of the epiglottis. Bronchoscopy failed to detect any white patches in her lower airway. The patient was kept intubated postoperatively and was extubated successfully on postoperative day 2.
Examination of the KOH prep revealed nonseptate pseudohyphae. Cultures of the epiglottic plaques detected Candida albicans. Bacterial cultures of the epiglottis revealed alpha-hemolytic streptococci. The epiglottic biopsy revealed fibrinous exudate with abundant fungal and bacterial organisms. No invasion was identified. The patient was treated with systemic antifungals and broad-spectrum antibiotics, and her respiratory status eventually improved.
Candida spp. are opportunistic pathogens that arise in immunocompromised patients; in fact, most cases of Candida epiglottitis have occurred in immunocompromised patients." (1,2) Our patient did have frank upper airway obstruction. This finding is consistent with a report of Candida epiglottitis in three immunocompromised patients described by Colman. (3) In that report, the three patients experienced odynophagia and pain, but their disease did not progress to upper airway obstruction. Early diagnosis and treatment of this rare opportunistic infection can prevent devastating sequelae.
(1.) Myer CM III. Candida epiglottitis: Clinical implications. Am J Otolaryngol 1997;18:428-30.
(2.) Gonzalez Valdepena H, Wald ER, Rose E, et al. Epiglottitis and Haemophilus influenzae immunization: The Pittsburgh experience--A five-year review. Pediatrics 1995;96:424-7.
(3.) Colman MF. Epiglottitis in immunocompromised patients. Head Neck Surg 1986;8:466-8.
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|Title Annotation:||Laryngoscopic Clinic|
|Author:||Mortelliti, Anthony J.|
|Publication:||Ear, Nose and Throat Journal|
|Date:||Jan 1, 2004|
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