Paediatric acute epiglottitis: not a disappearing entity

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Abstract

Objective: Paediatric epiglottitis is a serious, potentially life-threatening condition. Since the widespread introduction of the Haemophilus influenzae type b (Hib) conjugate vaccine in the UK in October 1992, there has been a dramatic reduction in its incidence. Vaccine failure is rare. The purpose of this study is to examine the failure rate of H. influenzae type b vaccine as measured by the number of cases of Haemophilus epiglottitis in fully vaccinated children presenting to a tertiary paediatric centre. A secondary aim is to provide a retrospective review of all cases of epiglottitis over a 13-year period. Methods: A retrospective case-note review identifying all cases of epiglottitis presenting to Alder Hey Hospital was undertaken covering the time period December 1987–January 2001. Details of patient age, sex, source of referral, clinical presentation, management and complications along with microbiological and serological findings were obtained. There were 21 males and 19 females. The mean age was 36 months (range 6–125 months). A provisional diagnosis was made on the basis of the clinical features, confirmed by direct laryngoscopy in all but two cases and further supported in 28 cases by a positive blood culture. Of the 40 children presenting with epiglottitis, eight (20%) presented after the introduction of the Hib conjugate vaccine. H. influenzae antibody titres were measured both in the acute and convalescent phases of illness by the central Haemophilus Reference Unit in Oxford. Results: We present the clinical features, management and complications of 40 cases of acute epiglottitis. H. influenzae was isolated from blood cultures in 28 cases (70%). In 12 of these cases, H. influenzae type b was identified, seven prior to 1993 and five thereafter. Four of these five cases presenting after introduction of the Hib vaccine were known to have been fully vaccinated. One child had a history of prematurity and serum immunoglobulin estimation was abnormally low in another child. Acute Hib antibody titre was less than 1 μg/ml in two of the three cases in which this was available. Conclusion: Whilst the incidence of Haemophilus type b epiglottitis has significantly diminished, vaccine failure does occur. We discuss the current understanding of clinical and immunological risk factors for vaccine failure and the significance of the Hib antibody titre. Further evaluation of vaccine failure would be of benefit. The series that we present highlights the importance of considering acute epiglottitis in the differential diagnosis of the child presenting with acute upper airway obstruction. This is particularly relevant when in future there will be fewer doctors familiar with the symptoms and signs of the disease.

Introduction

Paediatric acute epiglottitis is a serious, potentially life-threatening condition. Since the introduction of the Haemophilus influenzae (Hib) conjugate vaccine in the United Kingdom (UK) in October 1992, there has been a dramatic reduction in the incidence of infection [1]. The vaccine is routinely administered to infants at 2, 3 and 4 months of age. An uptake rate for vaccination for the total UK population is in the range of 89–96% [2]. Vaccine failure is rare.

An active surveillance programme for invasive Haemophilus disease has been established in several regions since 1990 and throughout the UK since 1995 [1]. In all cases, the local microbiologist is asked to provide isolates to the UK Haemophilus Reference Laboratory, in Oxford, for verification of the microbiological diagnosis.

The purpose of this study is to examine vaccine failure as measured by the rate of Hib epiglottitis since 1993 in fully vaccinated children presenting to a paediatric tertiary centre. A secondary aim is to provide a retrospective review of all cases of epiglottitis over a 13-year period. We present the serological findings in the cases of vaccine failure and refer to the current understanding of Hib vaccine failure.

Section snippets

Patients and methods

A retrospective case-note review at Alder Hey Hospital covering the time period December 1987–January 2001 has revealed that there were 40 cases of acute epiglottitis. The International Classification of Disease (ICD 9) diagnostic codes for Haemophilus infection and epiglottitis were used for case identification. There were 21 males and 19 females. The mean age was 36 months (range 6–125 months). The mean age was 34 months prior to 1993 and 44 months from that year. The total number of cases

Results

There was a total of 40 cases of epiglottitis, of which eight (20%) presented from 1993 onwards (Fig. 1). H. influenzae was isolated from blood cultures in 28 cases (70%). Of these, 12 were microbiologically-proven Hib infection with seven occurring prior to 1993. Clinical presentation was predominantly one of a toxic child with stridor and drooling. The mode of presentation of the cases of Hib vaccine failure varied considerably (Table 1).

The management of choice was admission to the intensive

Discussion

The introduction of Hib vaccination has led to a dramatic reduction in incidence of invasive H. influenzae infection [1], [4], [5]. Protection provided by the conjugate vaccine appears to also extend to unvaccinated children by herd immunity [6]. The first vaccines developed were composed of polyribosyl-ribitol phosphate (PRP), the capsular polysaccharide of the organism. Whilst these were highly efficacious in children older than 18 months, they provided no protection for younger infants [7].

Conclusion

Whilst the incidence of H. influenzae epiglottitis has diminished significantly since the advent of the Hib vaccine, vaccine failure although rare does not occur. We have presented a series of paediatric epiglottitis which has included cases of children who had been fully vaccinated. We have discussed the current understanding of vaccine failure and refer to the significance of clinical and immunological risk factors as well as the Hib antibody concentration.

This series highlights the

Acknowledgements

We thank the consultant paediatricians and intensive care physicians for their permission to present the cases under their care. We also thank the staff at the Oxford Vaccine Group, The University Department of Paediatrics, John Radcliffe Hospital, Headington, Oxford. They have kindly confirmed the Hib antibody titres and immunoglobulin levels as well as advised on the preparation of the manuscript. A special thanks to Dr J. McVernon.

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