Diagnostic Dilemma

Is it asthma?

A 9 months old boy born of third degree consanguineous marriage presented with recurrent cold and cough (more in mornings) for one and a half months associated with fever. Every time he was treated with some oral medications but had to be admitted 15 days ago and was treated with IV antibiotics, nebulization and oral steroids. He was discharged on Salbutamol metered dose inhaler (MDI) therapy, but there is no improved. There is no history of contact with tuberculosis or family history of asthma. On examination, child has tachypnea with respiratory rate of 34/min with subcostal retractions and continuously keeps mouth open, has congested nose. There are no rhonchi. Tonsils are normal.

Is this asthma?
Expert Opinion :
This child keeps his mouth open suggesting that he is not able to breathe from the nose. This suggests that airway above the mouth is obstructed either due to adenoids, or sinusitis or rhinitis. As a result, the child is trying to breathe harder leading to distress. The symptoms of recurrent cough and cold can also be explained due to these possibilities. Asthma in children presents as cough, which is predominantly night time and should improve with beta agonists. This child has no improvement on treatment of asthma, has no family history of allergy and does not have any rhonchi. Hence asthma seems unlikely. Sinusitis can lead to nasal drip which can cause early morning cough with rhinorrhea and mouth breathing. Adenoids are associated with enlarged tonsils and usually lead to snoring. In this child X-ray of paranasal sinuses showed opaque maxillary sinuses confirming the diagnosis of sinusitis.
Thus, not all recurrent cough and cold is LRTI and not all wheezing is asthma. Infact 20% of wheezing episodes may be due to sinusitis and need to be treated with antihistamines, decongestants and steam inhalation. Asthma is proven when PEFR increases by 20% on a beta agonist. If there is no improvement in PEFR, then other diagnosis must be considered.
Answer Discussion :
Malik Ahmad
Reactive airway disease
5 years ago
Jelena PanticVrsajkov
It may be nutritive allergy, reflux, adenoid hypertrophy, foreign body, Asthma....
5 years ago

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