Obstructive Lung Diseases: Obstructive Lung Disease |

An Unusual Case of Wheezing FREE TO VIEW

Pragya Rai, MD
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Sacred Heart Children's Hospital, Spokane, WA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A401. doi:10.1016/j.chest.2016.02.416
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SESSION TITLE: Obstructive Lung Disease

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: Recurrent wheezing is common in young infants and toddlers wit 27% of all chidlren having at least one wheezing episode by the age of 9 years (Robinson and Singh 2012). Congenital conditions causing wheezing disorders should not be missed and--not all wheezy bronchitis is or will become asthma (Horak E 2004).

CASE PRESENTATION: A 9-month-old girl was admitted in the pediatric intensive care unit (PICU) for hypoxemia and severe wheezing of one week duration. Her symptoms responded poorly to therapy with bronchodilators and racemic epinephrine. A history of fever, rhinorrhea, dysphagia, eczema and stridor were not reported. Upon transfer to the PICU, the child received systemic steroids, diuretics, anti-reflux medications; supplemental oxygen along with bronchodilator therapy was administered continuously. The patient had experienced wheezing the very first time at two months of age; she developed right upper lobe pneumonia due to aspiration from acetaminophen administration following vaccination. Since then, the child experienced recurrent episodes of wheezing on a monthly basis which appeared to be triggered by a viral like illness. She was treated with systemic steroids every two months. Therapy with inhaled steroids was started at the age of seven months with mild improvement. Review of ancillary studies at the time of admission was mostly unremarkable with normal complete cell count and serum electrolytes. A venous blood gas at the time of transfer to the PICU was notable for respiratory acidosis with ph 7.17 and a pCO2 65 torr. A chest radiograph (CXR) revealed a nodular opacity over the superior mediastinum on the right side, which could represent thymus but had an unusual counter. A CXR was repeated the following day which revealed less prominence of the previously seen nodular opacity; however, a repeat film after three days revealed persistence of the radiographic abnormality. A computed tomography scan revealed a fluid density mediastinal mass centered beneath the carina and compressing the bronchus intermedius as well as the left main stem bronchus. The patient underwent surgical resection of a large cyst noted at the sub carinal region and has remained asymptomatic ever since.

DISCUSSION: The differential diagnosis of an infant with wheezing is multifacorial; wheezing secondary to viral illness or as a sequlae being the most common.

CONCLUSIONS: On the other hand, it is important to consider other causes of wheezing such as with congenital anatomic abnormalities as in this case despite the history being similar to a child with wheezing from viral infections.

Reference #1: Allergy Asthma Proc. 2012 May-Jun;33 Suppl 1:S36-8. doi: 10.2500/aap.2012.33.3543. Chapter 11: the infant and toddler with wheezing. Robison RG1, Singh AM.

Reference #2: Wien Klin Wochenschr. 2004 Jan 31;116(1-2):15-20. [Wheezing in infants and toddlers: new insights]. [Article in German] Horak E1.

DISCLOSURE: The following authors have nothing to disclose: Pragya Rai

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