Clinical Communications: Pediatric| Volume 63, ISSUE 5, P673-677, November 2022

When Stridor is Not Croup: A Case Report

Published:September 10, 2022DOI:



      Croup is one of the most common causes of acute respiratory disorder in children. It presents as acute laryngeal symptoms in the context of viral infection. Treatment consists of systemic steroids and aerosolized adrenaline, after which the symptoms must resolve rapidly. There are many differential diagnoses, including neurological causes. In these cases, clinical presentation is atypical and the outcome can be less favorable.

      Case Report

      We present the cases of three children who presented with stridor, which was initially treated as croup but eventually turned out to have a neurological origin.

      Why Should an Emergency Physician Be Aware of This?

      Clinicians need to be aware of the differential diagnoses of croup. We suggest a few key points to help emergency physicians manage these patients, including adequate use of monitoring and nasofibroscopy. Early identification is a key element in the effective management of certain rapidly progressive neurological diseases.


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        • McDermott KW
        • Stocks C
        • Freeman WJ.
        Overview of pediatric Emergency Department Visits, 2015: Statistical Brief #242.
        Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Agency for Healthcare Research and Quality, Rockville, MD2006 (Available at:) (Accessed on March 22, 2022)
        • Denny FW
        • Murphy TF
        • Clyde WA
        • Collier AM
        • Henderson FW
        Croup: an 11-year study in a pediatric practice.
        Pediatrics. 1983; 71: 871-876
        • Pfleger A
        • Eber E.
        Assessment and causes of stridor.
        Paediatr Respir Rev. 2016; 18: 64-72
        • Van Bever HP
        • Wieringa MH
        • Weyler JJ
        • Nelen VJ
        • Fortuin M
        • Vermeire PA.
        Croup and recurrent croup: their association with asthma and allergy.
        Eur J Pediatr. 1999; 158: 253-257
        • Bjornson CL
        • Croup Johnson DW.
        Lancet. 2008; 371: 329-339
        • Rittichier KK.
        The role of corticosteroids in the treatment of croup.
        Treat Respir Med. 2004; 3: 139-145
        • Kothur K
        • Singh M
        • Dayal D
        • Gupta AK.
        Bilateral idiopathic vocal cord palsy.
        Pediatr Emerg Care. 2007; 23: 171-172
        • Daya H
        • Hosni A
        • Bejar-Solar I
        • Evans JNG
        • Bailey CM.
        Pediatric vocal fold paralysis: a long-term retrospective study.
        Arch Otolaryngol Neck Surg. 2000; 126: 21-25
        • de Jong AL
        • Kuppersmith RB
        • Sulek M
        • Friedman EM.
        Vocal cord paralysis in infants and children.
        Otolaryngol Clin North Am. 2000; 33: 131-149
        • Emery PJ
        • Fearon B.
        Vocal cord palsy in pediatric practice: a review of 71 cases.
        Int J Pediatr Otorhinolaryngol. 1984; 8: 147-154
        • Ross DA
        • Ward PH.
        Central vocal cord paralysis and paresis presenting as laryngeal stridor in children.
        Laryngoscope. 1990; 100: 10-13
        • Koepke R
        • Sobel J
        • Arnon SS.
        Global occurrence of infant botulism, 1976–2006.
        Pediatrics. 2008; 122: e73-e82
      1. Centers for Disease Control and Prevention (CDC). Botulism: epidemiological overview for clinicians. Available at: Accessed June 8, 2021.

        • King L-A
        • Popoff M-R
        • Mazuet C
        • Espié E
        • Vaillant V
        • de Valk H
        Le botulisme infantile en France, 1991–2009.
        Arch Pediatr. 2010; 17 ([in French]): 1288-1292
        • Godart V
        • Dan B
        • Mascart G
        • Fikri Y
        • Dierick K
        • Lepage P.
        Botulisme infantile après exposition à du miel.
        Arch Pediatr. 2014; 21 ([in French]): 628-631
        • Bernardor J
        • Neveu J
        • Haas H
        • et al.
        Infant botulism: two case reports and electroneuromyogram findings.
        Arch Pediatr. 2018 Jun 7; ([Online ahead of print])
        • Delannoy A
        • Rudant J
        • Chaignot C
        • Bolgert F
        • Mikaeloff Y
        • Weill A.
        Incidence du syndrome de Guillain-Barré en France : une analyse épidémiologique à partir des données du PMSI (2008–2013).
        Rev d’Épidémiologie Santé Publique. 2017; 65 ([in French]): S7
        • Agrawal S
        • Peake D
        • Whitehouse WP.
        Management of children with Guillain-Barré syndrome.
        Arch Dis Child Educ Pract Ed. 2007; 92: 161-168
        • Shahrizaila N
        • Lehmann HC
        • Kuwabara S.
        Guillain-Barré syndrome.
        Lancet. 2021; 397: 1214-1228
        • Korinthenberg R
        • Schessl J
        • Kirschner J.
        Clinical presentation and course of childhood Guillain-Barré syndrome: a prospective multicentre study.
        Neuropediatrics. 2007; 38: 10-17
        • Korinthenberg R
        • Trollmann R
        • Felderhoff-Müser U
        • et al.
        Diagnosis and treatment of Guillain-Barré Syndrome in childhood and adolescence: an evidence- and consensus-based guideline.
        Eur J Paediatr Neurol. 2020; 25: 5-16
        • Mishra BK.
        Post infective polyradiculoneuropathy with bilateral recurrent laryngeal nerve palsy.
        J Assoc Physicians India. 1989; 37: 617
        • Panosian MS
        • Quatela VC.
        Guillain-Barré syndrome presenting as acute bilateral vocal cord paralysis.
        Otolaryngol Head Neck Surg. 1993; 108: 171-173
        • Yoskovitch A
        • Enepekides DJ
        • Hier MP
        • Black MJ.
        Guillain-Barré syndrome presenting as bilateral vocal cord paralysis.
        Otolaryngol Head Neck Surg. 2000; 122: 269-270
        • Rodrigues JF
        • York EL
        • Nair CP.
        Upper airway obstruction in Guillain-Barré syndrome.
        Chest. 1984; 86: 147-148
        • Hsia S-H
        • Lin J-J
        • Wu C-T
        • Huang I-A
        • Lin K-L.
        Guillain-Barré syndrome presenting as mimicking croup.
        Am J Emerg Med. 2010; 28 (749.e1–3)