Case presentation A three-year-old boy presented to the emergency department with a three-day history of fever and a one-day history of a barking cough. Vital signs Blood pressure: 132/73 mmHg Heart rate: 180 bpm Respiratory rate: 42 breaths per minute Temperature: 38.2 ° C Oxygen saturation: 93% on 3 L/min of oxygen via a non-rebreather mask Physical examination Inspiratory stridor Reduced air entry bilaterally on auscultation Substernal retractions Elevated blood pressure in the ED attributed to sympathetic stimulation from tension, anxiety, and increased respiratory effort Blood pressure after ICU admission: 106/66 mmHg Initial diagnosis and management Initial diagnosis: Croup Treatment initiated: Nebulized epinephrine Oral dexamethasone Persistent symptoms despite five days of therapy: Severe sore throat Odynophagia Drooling Lack of response prompted consideration of an alternate…