Case 13 Flashcards
What is a typical case presentation of asthma?
6 yo with six week history of persistent cough that is worse at night, with activity, and with exposure to cold. History of allergies and eczema. Family history of asthma.
What are key findings from the history of a child with asthma?
Recent history of URI, nasal congestion, cough worse at night, cough worse with activity and cold, history of eczema, positive family history of asthma.
What are key findings from the physical exam of a child with asthma?
Allergic shiners, clear nasal secretions, end-expiratory wheeze
What is on the differential diagnosis for asthma?
Asthma, bronchitis, sinusitis, allergies, habitual cough, atypical pneumonia, GERD
What are key findings from testing a child with asthma?
CXR: mild hyperinflation.
Spirometry: Mild, reversible obstructive defect.
Atopy:
A genetic predisposition - compounded by environmental factors - leads to the development of an IgE-mediated response (allergic rhinitis, asthma, and/or atopic dermatitis) to common inhalation allergens (including house dust mites, animal dander, and cockroaches, fungi, and some grass and ragweed pollens). Children of an atopic parent have a 30 percent risk for developing an atopic disorder and are more likely to become sensitized when exposed to allergens.
What is the epidemiology of asthma in children?
- Number of people affected by asthma has more than doubled in past 15 years
- Now most common pediatric chronic disease, afflicting nearly 5 million children less than 18 yrs in the US
- Accounts for 19 million missed school days, greater than 3 million physician visits, and 200,000 pediatric hospitalizations each year.
- More than 5,500 people die from asthma every year
What is the pathophysiology of asthma?
Biphasic inflammatory response:
- Early asthmatic reaction (first hour): Mast cells and eosinophils release mediators such as prostaglandins and leukotrienes, leading to increased vascular permeability, mucus hypersecretion, and rapid bronchoconstriction.
- Late asthmatic reaction (begins 2-3 hours later, reaches a maximum by about 4-8 hours and resolves in about 24 hours). Neutrophil, eosinophil, and lymphocyte infiltration of bronchial epithelium results in epithelial destruction, fibrotic remodeling, and hyperplasia of the bronchial smooth muscle. Increase in airway hyper responsiveness may persist for days to weeks after the late reaction appears to have resolved.
Diagnosis of asthma is based on the following:
- History (episodic nature, precipitating factors, and family history)
- Physical examination
- Pulmonary function testing before and after bronchodilator therapy
NIH/NAEPP classification of asthma severity:
This classification system is based on an algorithm combining frequency of symptoms, nocturnal symptoms, and PFT results. Asthma severity is classified as either:
-Intermittent (mild) or
-Persistent (mild, moderate, and severe)
Note: Two additional recognized clinical forms of asthma that are not included in this classification are exercise-induced asthma (severe bouts of bronchospasm triggered only by exercise or cold air) and cough-variant asthma (presents only with cough).
What is the epidemiology of primary pulmonary tuberculosis (TB)?
- In US, most children infected with Mycobacterium tuberculosis in the home by someone close to them
- Outbreaks may occur in daycare centers and schools
- Case rates for ages highest in urban, low-income areas and in foreign-born children, among whom more than two thirds of reported cases in the US now occur
- A diagnosis of TB in a young child is a public health sentinel event usually representing recent transmission
What are signs and symptoms of primary pulmonary tuberculosis (TB)?
- Most children have few to no symptoms, often in sharp contrast to the degree of radiographic changes
- Greater than 50 percent of infants and children with radiographically evident disease have no physical findings and are discovered only by contact tracing.
- Infants and toddlers are more likely to experience symptoms such as nonproductive cough, mild dyspnea, or wheezing (due to bronchial compression by enlarged regional lymph nodes).
- Infants may present with failure to thrive
- Severe cough and sputum production, together with systemic complaints such as fever, night sweats, and anorexia, usually signify intrapulmonary dissemination
- Systemic symptoms such as night sweats and weight loss are uncommon
Radiographic findings of tuberculosis:
- The hallmark of TB in the lung is the primary complex
- The size of hilar lymphadenopathy is relatively large compared with the size of the initial lung focus
- A sequence commonly seen is:
- -Hilar adenopathy (most common radiographic abnormality)
- -Focal hyperinflation
- -Atelectasis, with minimal evidence of the primary lung focus itself
- All lobar segments of the lung are at equal risk of initial infection
- Two or more primary foci are present in 25 percent of cases.
- Findings may be confused with foreign body obstruction
- Small local pleural effusions are common; large effusions rarely seen in children less than six years of age
How do you diagnose TB in a child without symptoms?
- Mantoux skin test is the only practical tool for diagnosing TB infection in an symptomatic child
- -Formerly called a PPD (purified protein derivative), now more correctly referred to as TST (tuberculin skin test)
- TST considered positive if it is:
- -Greater than 5 mm in high-risk children
- -Greater than 10 mm in moderate-risk children
- -Greater than 15 mm in low-risk children
How do you diagnose TB in a child with symptoms?
Culture of the M. tuberculosis organisms should be obtained from a sputum sample, or from a first morning gastric aspirate in young children
Dry cough
Environmental irritant, asthma, fungal infection
Productive, “wet” or “congested” cough
Lower respiratory infection
Barking cough
Croup, subglottic disease, or foreign body
Brassy or honking cough
habitual cough, tracheitis
Paroxysmal cough
Pertussis, chlamydia, mycoplasma, foreign body
Worse at night cough
Asthma, allergies, sinusitis
Disappears at night cough
Habitual cough
Associated with gagging or choking cough
Gastroesophageal reflux
Precipitating factors such as cold or activity - cough
Asthma
What does dysphonia or hoarseness suggest?
Laryngeal irritation from chronic rhinitis or gastroesophageal reflux.
Chest pain or palpitations:
True cardiac chest pain is rare in children. Substernal pain may suggest gastroesophageal reflux. Palpitations may suggest congestive heart failure.
Dyspepsia or regurgitation:
Gastroesophageal reflux
History of choking:
Foreign body aspiration or aspiration pneumonia (especially in children with neurologic impairment)