Grand Rounds


Medical Sciences Department, Pediatric Oncall, Mumbai, India

Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056, India.

Clinical Problem :
A 1½ years old presented with recurrent episodes of cough since 4 months of age. He was hospitalized 4 times. First admission – at 4 months of age for LRTI. Treated with antibiotics for 7 days. Echocardiography done at that time showed moderate size VSD. A repeat echocardiography done after 1 month showed spontaneous closure of VSD. Second admission at 9 months of age for bronchopneumonia. Treated with antibiotics, steroids and beta agonist nebulization. Third admission at 1 year of age for bronchitis. Treated with nebulization and steroids and antibiotics. Fourth admission at 1½ years of age and treated with antibiotics, magnesium sulfate and nebulization. Chest X-Ray done was normal. He also had an episode of diarrhea 1 month ago. Patient was put on Budesonide inhaler for past 2 months. There is history of asthma in great grandfather. Birth history, milestones are normal. He is immunized till date. He has a poor unbalanced diet predominantly on milk and biscuits. He was exclusively breast fed till 7 months and then weaning was started. On examination his weight is 8 kg and height is 73 cm. Other examination findings are normal.

Investigations showed:
? Chest X-Ray = Normal
? Hemoglobin = 8.9 gm, dl, WBC = 13,000, cumm {polymorphs 16 percent, lymphocytes = 83 percent, eosinophil = 1 percent, MCV 29.4 percent, MCHC = 57.5 ft, RDW = 18.5 percent, Reticulocyte = 0.4 percent, Platelets = 9,19,000, cumm.
? ESR = 5 mm at end of 1 hour
? Serum calcium = Normal
? Serum IgG, IgA, IgM = Normal
? HRCT Chest = Subcarinal lymphadenopathy {solitary} = 0.8 cm just below right bronchus without central caseation.
? Mantoux test = Negative
? S. IgE = Normal
? Gastric lavage for Acid Fast Bacilli = Negative
? HIV ELISA = Negative.

Does this child have asthma_? Does this child have TB_?

Discussion :
This child has had recurrent respiratory infections. First infection may be related to the VSD and increased pulmonary blood flow. Subsequent hospitalizations have all required nebulization and antibiotics. Thus it is not clear whether the child had a wheezing episode or infection. There is history of “asthma” in great grandfather. This is suggestive of breathlessness in a 4th generation relative where diagnosis may be even COPD, smoking, cardiac asthma or even tuberculosis. Thus there is no clear cut history of asthma in family. Also the child has been alright in between the episodes suggestive that it is not a persistent disease. Serum IgE is also normal not suggesting an allergic phenomenon. Thus asthma does not seem to be the problem in this child.
Regarding TB, it does not cause recurrent infections over a period of 1 year. The child has no contact with a patient with TB, his Mantoux test is negative and ESR is also normal. CT scan is suggestive of subcarinal single lymphnode. In TB, there would be multiple lymphnodes with central caseation which could be very well picked up on a CT scan. Thus tuberculosis is also unlikely in this child.
The child’s diet is very poor and he is also underweight, has anemia and probably other micronutrient deficiency which can lead to recurrent infections. As explained 1st admission at 4 months may be due to VSD. Subsequent admissions have been after the weaning process has been initiated. Poor nutrition can lead to increased susceptibility to infections. In addition to respiratory infections, the child also had diarrhea suggestive of both GI and respiratory system affection. HIV, hypogammaglobulinemia have been excluded as the probable immunodeficiencies. Thus, most likely, all the problems in this child may be due to his nutritional status. A repeat CT reporting was suggestive of reactive lymph node most likely due to viral infection and CBC was also suggestive of lymphocytosis in this child again pointing to a recent viral infection. The child was treated with proper diet and micronutrient supplements. He has been asymptomatic ever since.

Correct Answers :  yes 7%
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