CLIPP case 12. 10 month-old with cough

Question 1

Differential of cough

Answer 1

• Asthma
• Epiglottitis
• Anatomic
• Pertussis
• Bronchiolitis
• Croup
• Gastroesophageal reflux
• Foreign body
• Pneumonia

Question 2

Causes of cough now uncommon but must be considered in unimmunized or partially immunized children

Answer 2

• Pertussis
• Diphtheria
• Epiglottitis

Question 3

Pertussis

Answer 3

Bordatella pertussis. Triphasic:
1. Catarrhal stage (1-2 wks): URI-like
2. Paroxysmal stage (4-6 wks): Repetitive, forceful coughing episodes followed by massive inspiratory effort, which results in
characteristic “whoop” (quick staccato cough).
2. Convalescent stage: Cough gradually decreases in severity and frequency.
Episodic cough may persist for months.

Question 4

Diphtheria

Answer 4

Corynebacterium diphtheria: Should be considered in a child with pharyngitis and low-grade fever, particularly if stridor or hoarseness is present. A characteristic gray pseudomembrane is seen in the pharynx.

Question 5

Epiglottitis

Answer 5

H. influenzae B: Life-threatening illness. Consider in child with stridor and severe respiratory distress, especially if with drooling, dysphonia, and/or dysphagia.

Question 6

Croup

Answer 6

Laryngeotracheobronchitis. Parainfluenzae. Barky cough. Winter. Ages 2-5.

Question 7

Visible signs of respiratory distress in infants

Answer 7

• Paradoxical breathing: Worst sign. Drawing in the chest wall during inspiration instead of moving outward with the abdomen.
• Tachypnea: Note depth and degree of effort.
• Grunting: Forced expiration against a partially closed glottis. Suggests diseases of air space such as atelectasis, pneumonia, or pulmonary edema.
• Nasal flaring: Enlargement of both nares to increase air entry.
• Head bobbing: Best observed during sleep. In synchrony with each inspiration, shows use of accessory muscles.
• Subcostal/intercostal retractions: An inspiratory sinking-in of soft tissues in relation to cartilaginous and bony thorax.

Question 8

URI

Answer 8

Extremely common in childhood. Presents with wet cough, rhinorrhea, usually no wheezing. Asymmetric breath sounds are not consistent with a viral process

Question 9

Asthma

Answer 9

• Reversible airway obstruction
• Inflammation with mucus hypersecretion, mucosal edema, and bronchoconstriction
• CXR: hyperinflation, increased interstitial markings, and patchy atelectasis.

Question 10

Bronchiolitis

Answer 10

-LRI (RSV)
-Most common cause of wheezing in infants
-Bronchiolar obstruction from edema, mucus,
and cellular debris
-Mild URI -> cough, wheezing, dyspnea, and irritability
-CXR: hyperinflation, peribronchial cuffing, and scattered atelectasis.

Question 11

Pneumonia

Answer 11

• Inflammation of lung parenchyma, by microorganisms, gastric contents or hydrocarbons.
• Most common cause in children is viruses (adenovirus, RSV, parainfluenza, and influenza)
• Bacterial: GBS, E. coli, Klebsiella, C. trachomatis, S. pneumoniae, Mycoplasma
• CXR: airspace disease with lobar or segmental consolidations and air bronchograms.

Question 12

Foreign body aspiration

Answer 12

• 500 childhood deaths a year in the U.S.
• Hot dogs, hard candy, nuts, grapes, popcorn. -Asymmetric wheezing on exam
• CXR: Unilateral air trapping in one lung.
• Local tissue reaction: Disc battery worst and may erode through bronchial wall > Fatty oils (peanuts) cause severe pneumonitis > plastic or metal
• Get inspiratory/expiratory CXR, decubitus CXR, chest fluoroscopy for diagnosis
• Rigid bronchoscopy for removal