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Joana Rosa1; Raquel Amaral1; António Paiva2; Anuschka Langner3; Marta Oliveira4; Vera Brites4; João Estrada4

1. Departamento de Pediatria, Hospital do Divino Espírito Santo, Ponta Delgada
2. Departamento de Anestesiologia, Hospital do Divino Espírito Santo, Ponta Delgada
3. Unidade de Cuidados Intensivos Neonatais, Hospital do Divino Espírito Santo, Ponta Delgada
4. Unidade de Cuidados Intensivos Pediátricos, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, EPE, Lisboa

- European Academy of Pediatrics Congress 2019, Porto, 19-22/09/2019 

Background/Objective:  Haemophilus influenzae type b (Hib) can be responsible for severe and life-threatening infections, such as epiglottitis. Since the introduction of Hib conjugate vaccine, it was observed a considerable reduction in Hib invasive disease and a decrease in community nasopharyngeal carriage.
Case report: A healthy and fully immunized 5-year-old girl was admitted to the pediatric emergency department with sore throat, dyspnea and stridor. Physical examination revealed respiratory distress and diminished vesicular sounds. The general condition worsened after nebulized L-epinephrine and dexamethasone, culminating in an ill-looking appearance. Epiglottitis was suspected and intubation material was being prepared when the patient went into cardiopulmonary arrest. Advanced pediatric life support maneuvers were carried out for 15 minutes, which included a difficult intubation procedure and neuroprotective measures. She was transfer to intensive care unit and connected to mechanical ventilation. Laboratory analysis revealed leukocytosis 31.46x109/L, neutrophilia 29 x109/L, C-reactive protein 7.88mg/dL and procalcitonin 46.7ng/mL. She was medicated with cefotaxime, clindamycin and metronidazole. Multiplex PCR detected Haemophilus influenza and microbiologic analysis confirmed Hib. She also had myoclonic movements, after cardiopulmonary arrest, and the cranioencephalic CT scan together with Transcranial Doppler ultrasound (TCD) showed cerebral edema. The electroencephalogram presented a status epilepticus and as so phenobarbital, propofol, levetiracetam, and 3% sodium chloride were initiated. The patient was referred to a pediatric intensive care unit in a tertiary hospital. She was evaluated by pediatric neurology and MRI exam revealed severe hypoxic-ischemic brain injury. The neurologic exam showed a progressive deterioration, reporting an irreversible loss of brain function, including the brain stem. Electroencephalogram showed isoelectric trace and TCD demonstrated cerebral circulatory arrest, having been decided to withdrawal life support.
Conclusion: Despite the high efficacy of Hib vaccine, invasive Hib disease can occur and be fatal in apparently immunocompetent and immunized child. Epiglottitis should continue to be consider in patients with dyspnea and stridor.

Palavras-chave: epiglottitis; Haemophilus influenzae type b; hypoxic-ischemic brain injury; immunization; pediatric intensive care.