"Not another sore throat!"
Why are the saltwater gargles not helping?
Vol.16, No.06, June 2008

Bernadette, a 52-year-old librarian, presents to the emergency department (ED) at 2pm complaining of severe pain swallowing, which began earlier that morning. She attempted gargling with warm saltwater, but that brought no relief. She also started to have a fever and chills while at home.

Her medical history is significant only for type 2 diabetes mellitus and osteoarthritis. She's taking meloxicam for the arthritis and glyburide to control the diabetes. On exam, Bernadette appears well with normal speech. Her vital signs are as follows:

  • heart rate (HR): 110 beats/min
  • blood pressure (BP): 128/78 mm Hg
  • respiration rate (RR): 22 breaths/min
  • temperature (T): 37.8° C
  • oxygen saturation (SaO2): 98% on room air.

The pharynx is minimally erythematous with no exudates, and there are 2 palpable tender cervical lymph nodes (< 0.5 cm). The remainder of the exam is unremarkable.

She's being diagnosed with viral pharyngitis and is discharged home with the advice to continue with saltwater gargles. The treating physician also recommends that she take anti-pyretics and analgesics, and he tells her to return to the ED if symptoms worsen or if she doesn't improve.

At 1am the next morning, Bernadette returns to the ED. She complains of worsening odynophagia and increasing difficulty with swallowing both solids and fluids. She still has a fever. Re-examination of her throat doesn't reveal any changes from the previous exam, but her voice is now hoarse. Repeat vitals reveal a HR of 116 beats/min, BP at 126/74 mm Hg, RR at 24 breaths/min, T of 38.2° C and SaO2 of 96% on room air.

A throat culture is obtained and the patient is sent for a soft tissue neck x-ray (see Figure). What's the etiology of her sore throat?

Why does Bernadette have difficulty swallowing?


Bernadette has adult epiglottitis. She was admitted to the hospital and underwent fiberopticlaryngoscopy without complication, which confirmed the diagnosis. Laboratory evaluation revealed a total white blood cell count of 11 x 109/L and glucose at 13 mmol/L; all other laboratory tests were normal. Culture of the pharynx was negative, as were blood cultures. The patient was treated with intravenous antibiotics and discharged home on day 5 after admission.

Red flags for epiglottitis:

  • severe sore throat
  • complaints of difficulty swallowing
  • when patients return to their MD multiple times with sore throat and persistence of symptoms

We'll send you $100 if we print your diagnostic challenge. Send case description (app. 450 words) with final diagnosis and outcome to: parkex@parkpub.com.

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