WHAT'S YOUR DIAGNOSIS?
ANSWER: REACTIVE AIRWAY DISEASE
Case 1. The chest radiograph, which is slightly rotated as evidenced by the clavicles, shows a normal heart contour with an upper border merging with thymic tissue, a right middle lobe infiltrate, and peribronchial cuffing in both lung fields. A lateral film (not shown) revealed flattening of the diaphragm, suggestive of hyperinflation and/or air trapping.
Although congestive heart failure might be considered on the basis of the patient’s symptoms, the intermittent wheezing, stable cardiac lesions, and acute pulmonary infiltrate favor a diagnosis of recurrent respiratory illness, manifested as acute bronchiolitis and right middle lobe pneumonia.
Case 2. The chest radiograph, which is minimally rotated, shows right middle lobe atelectasis, supported by a slight rightward shift of the mediastinum and mild hyperinflation in the upper and lower lung fields bilaterally. Persistent wheezing with right middle lobe atelectasis is suggestive of asthma.
RECOGNITION OF RECURRENT RESPIRATORY DISEASE
Reactive airway disease, whether transient or persistent, is one of the most common pediatric complaints.1 The essential symptom of wheezing may appear insidiously at night with accompanying cough, after exercise (which in infants can include crying or excitement), or with respiratory distress and fever that reflect bronchiolitis or pneumonia or both. Pediatricians must recognize the initial symptoms of wheezing, tachypnea, and/or cough; document their recurrence and frequency; and eliminate other causes before making a diagnosis of asthma.
About 12.7% of children receive an asthma diagnosis some time before age 18 years; this amounts to 6 million children in the United States.1 Despite the advent of remarkably effective therapies and protocols,2 asthma still causes 7 million ambulatory visits; 200,000 hospitalizations; and 13 million missed school days each year.
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3. Strunk RC. Defining asthma in the preschool-aged child. Pediatrics. 2002;109
4. Plint AC, Johnson DW, Patel H, et al; Pediatric Emergency Research Canada
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5. American Academy of Pediatrics Subcommittee on Diagnosis and Management
of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118:
6. Gershel JC, Goldman HS, Stein RE, et al. The usefulness of chest radiographs
in first asthma attacks. N Engl J Med. 1983;309:336-339.