An otherwise healthy, full-term, fully immunized 5-year-old boy presented to the emergency department after he developed decreased energy, decreased appetite, sore throat, drooling, refusal to speak, and a fever to 102°F over a period of 6 hours in the setting of 5 days of rhinorrhea and a “croupy” cough.

On presentation, his weight was 22 kg and blood pressure was 102/56 mm Hg, with a respiratory rate of 32 breaths per minute, a heart rate of 132 beats per minute, a pulse oxygen saturation (Spo2) of 99% in ambient air, and a temperature of 38°C (100.4°F). He was ill-appearing and was noted to be in moderate respiratory distress, with refusal to speak and sitting with his neck extended in his mother’s lap.

Physical examination revealed an erythematous posterior oropharynx with diffuse anterior and posterior cervical lymphadenopathy. His lungs were clear to auscultation bilaterally, without stridor or sterter....

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