2025 – PAGE 431 – PULMONOLOGY

BETA BLOCKERS AND ASPIRIN

Beta blockers and aspirin can cause a fast and severe asthma exacerbation in some patients.

ADULT ASTHMA

More than half of pediatric asthma is “outgrown” and does not lead to adult asthma.

PEARLS: If a child was less than 3 years old when the asthma started, or has eosinophilia, elevated IgE, or maternal history of asthma, then there is an increased risk of developing persistent asthma into adulthood.

ASTHMA DIFFERENTIAL

A cough can also = GERD or sinusitis. Also, “all that wheezes is not asthma.” So, if a child presents with wheezing that does not change/improve with bronchodilators, consider a different diagnosis, such as a foreign body, vascular ring, vocal cord paralysis, or tracheal stenosis.

PEARL: Wheezing localized to one side with an ipsilateral decrease in breath sounds should also make you think of a FOREIGN BODY. The same goes for a URI that won’t resolve.

PNEUMONIA

A pneumonia can be diagnosed based on symptoms and clinical findings alone. If a patient has a fever, chills, cough, crackles in the right lower lobe, and a clear chest X-ray, s/he has a right lower lobe pneumonia. Seeing an infiltrate obviously makes the diagnosis easier. Mild cases can be treated empirically but BLOOD CULTURE should be obtained in more ill children to look for an etiology since children are usually not very good about providing a helpful sputum sample. This chapter will focus on recurrent and migrating pneumonias.

RECURRENT PNEUMONIA

The differential is quite wide for recurrent pneumonias. This theme is frequently seen on the pediatric certification and recertification exam. Some of the conditions associated with recurrent pneumonia are listed in this section.

ATAXIA TELANGIECTASIA

Ataxia telangiectasia findings include an elevated alpha-fetoprotein, possible eye findings, telangiectasias, and possible ataxia.

X-LINKED AGAMMAGLOBULINEMIA (AKA BRUTON’S AGAMMAGLOBULINEMIA)

For X-linked agammaglobulinemia, look for a male child with a history of infections caused by encapsulated organisms, including H. influenzae, Streptococcus pneumoniae, and Pseudomonas. Also look for an absence of lymphadenopathy and tiny tonsils.

SEVERE COMBINED IMMUNODEFICIENCY (SCID)

Severe combined immunodeficiency (SCID) is a T and B cell deficiency. Look for persistent viral infiltrates, a history of otitis media (at 3–6 months of age), and a lymphopenia or a low absolute lymphocyte count.

HYPER-IGM SYNDROME (AKA HYPER IGM SYNDROME)

In hyper-IgM syndrome (AKA hyper IGM), there are no IgGs because the switch from IgM to IgG doesn’t occur (T-cells are not giving B cells the signal). Look for a lymphocytosis, neutropenia.