What is the best course of action for a 3-year-old male with a dry cough, fever, and minor erythema of the right tympanic membrane, who recently received a COVID-19 (coronavirus disease 2019) booster?

Differential Diagnosis and Management

Most Likely Diagnosis

This presentation is most consistent with a post-vaccination febrile reaction rather than acute otitis media (AOM), given the temporal relationship to COVID-19 booster (48 hours prior) and only minor tympanic membrane erythema without bulging or purulent drainage. 1

Key Clinical Distinctions

Post-Vaccination Reaction (Most Likely)

• Fever occurring 24-72 hours after COVID-19 vaccination is a common expected reactogenicity 1
• Dry cough without congestion can occur as part of systemic vaccine response 1
• Minor TM erythema alone does not meet criteria for AOM 2, 3
• Symptoms typically resolve within 48-72 hours without intervention 1

Acute Otitis Media (Less Likely)

AOM requires a distinctly bulging tympanic membrane with acute inflammatory signs—not just minor erythema. 4 The case describes only "minor erythema" without mention of bulging, which is insufficient for AOM diagnosis. 2, 3

If this were true AOM, the bacterial pathogens would be Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, requiring beta-lactam coverage. 2, 3

COVID-19 Infection

While COVID-19 can present with fever and cough, the temporal relationship to vaccination (48 hours) and lack of congestion make post-vaccine reaction more likely. 5, 6 Consider COVID-19 testing if symptoms persist beyond 72 hours or worsen. 1

Recommended Management Algorithm

Immediate Assessment (Day 1-3)

• Provide symptomatic treatment only (antipyretics, hydration) 1
• Do NOT prescribe antibiotics at this stage—minor TM erythema with normal landmarks is not an indication for antibiotics 3
• Counsel family that fever and systemic symptoms within 48-72 hours of COVID-19 vaccination are expected 1

Reassessment at 48-72 Hours

If symptoms persist or worsen:

• Re-examine tympanic membrane for bulging (not just erythema) 2, 3
• If TM now shows distinct bulging with purulent appearance: diagnose AOM and prescribe amoxicillin-clavulanate, cefuroxime-axetil, or cefpodoxime-proxetil for 8-10 days (child <2 years) 2, 3, 4
• If TM remains non-bulging: continue observation, consider COVID-19 testing 1

If symptoms resolve:

• No further intervention needed—confirms post-vaccination reaction 1

Critical Pitfalls to Avoid

• Never prescribe antibiotics without adequate visualization showing a distinctly bulging tympanic membrane 2, 3
• Do not diagnose AOM based on isolated TM redness with normal landmarks—this leads to unnecessary antibiotic exposure 3
• Avoid attributing all post-vaccination symptoms to infection—fever within 48-72 hours of COVID-19 booster is expected reactogenicity 1
• Do not use fluoroquinolones (ofloxacin, ciprofloxacin) if AOM is diagnosed, as they lack adequate pneumococcal coverage 3

When to Escalate Care

• Symptoms persisting beyond 72 hours despite appropriate management 2
• Development of respiratory distress, hypoxia, or signs of severe illness 1
• TM perforation with purulent drainage unresponsive to first-line antibiotics 2
• Signs of complications (mastoiditis, meningitis) 2

Special Consideration for This Age Group

Children under 2 years require 8-10 days of antibiotic treatment if AOM is confirmed (versus 5 days for older children/adults). 3, 4 However, this only applies if true AOM with bulging TM is documented—not for minor erythema alone. 2, 3