A 2-year-old with a recent viral URI develops a barky cough and high fever with progressive respiratory distress; lateral neck radiograph shows subglottic and tracheal narrowing. What is the most likely diagnosis?

• A. Acute epiglottitis
• B. Bacterial tracheitis
• C. Acute spasmodic croup
• D. Laryngotracheobronchitis (croup)

Answer: (B)

In a toddler who recently had a viral URI and develops a barky cough with high fever and progressive respiratory distress, think about a bacterial infection causing airway obstruction rather than simple viral croup. Bacterial tracheitis tends to present after a viral illness with a toxic appearance and high fever, and the airway obstruction can worsen despite initial treatments. Imaging often shows subglottic and tracheal narrowing with irregular or even pseudomembranous changes, reflecting inflammatory exudates sloughing within the trachea. This contrasts with classic viral croup, which typically shows smoother, more uniform subglottic narrowing (the steeple sign) on radiographs and usually presents with milder fever. Epiglottitis would more classically present with drooling and a toxic pose with a thumbprint sign on lateral views, not primarily subglottic/tracheal narrowing. The combination of a high fever, progression to airway distress, and irregular narrowing of the subglottic/tracheal region on radiograph best fits bacterial tracheitis.