Post on 28-Nov-2014
Recurrent Resp Recurrent Resp symptoms / infectionssymptoms / infections
Recurrent Resp Recurrent Resp symptoms / infectionssymptoms / infections
Dr S.Ramesh 31Oct 2010
Scope of this talkScope of this talk
The differential diagnosis of rec resp infections
symptoms signs
How would you work up such a case
The differential diagnosis of rec resp infections
symptoms signs
How would you work up such a case
Respiratory tract infectionsRespiratory tract infections
URTI
LRTI
URTIURTI
Common cold
Tonsillitis
Pharyngitis
Sinusitis
Laryngitis
ALTB
Epiglottitis
LRTILRTI
Pneumonia
Bronchiolitis
Bronchitis
WALRI
SymptomsSymptoms
Cough
Cough with sputum production
Running nose
Purulent nasal secretions
SignsSigns
Stridor
Rhonchi
Creps
Air entry
Causes of recurrent or persistent resp signs and symptoms
Recurrent ‘normal’ infections Very common
Asthma Very common
Prolonged infection (e.g. pertussis, mycoplasma, RSV)
Common
Cigarette smoking (passive/active) Common
Habit or psychogenic cough Common
Idiopathic Common
Differential diagnosis of Differential diagnosis of
recurrent chest infectionsrecurrent chest infections Normal immune and respiratory defences
Normal growth
Normal but unlucky
Children have 6-10 URTI /yr
Peak incidence 6-12 months
Entry to school
AsthmaAsthma
Most children with recurrent chest infections or
a persistent cough will be shown to have
undiagnosed asthma
Cough variant asthma
Questions to ask in suspected cough Questions to ask in suspected cough
variant asthmavariant asthma
Trigger factors for URTI exercise, cold exposure
to pets
Family history of atopy
Whether to give a trial of bronchodilators or not
Diagnosis may be difficult under 3 yrs
Post infective coughPost infective cough
Cough can persist for 2-6 months
B.Pertussis / M Pneumoniae
Hyperactive cough receptors
Post infective recurrent wheezePost infective recurrent wheeze
WALRI
Post Bronchiolitis syndrome
Causes of recurrent or persistent cough
Aspiration Uncommon
Gastro-oesophageal reflux Uncommon
Incoordinate swallowing Uncommon
Intrabronchial foreign body Uncommon
Mediastinal or pulmonary tumours Very rare
Inhaled foreign bodyInhaled foreign body
Peanuts “Only a nut gives nuts to his child”
Air entry
ACUTE BACTERIAL SINUSITISACUTE BACTERIAL SINUSITIS
Nasal or Post nasal discharge of any quality with or without day time cough for 10 to 14 days
Purulent nasal discharge with high fever for 4 days
Chronic suppurative lung diseaseChronic suppurative lung disease
Cough with sputum production
Causes of recurrent or persistent cough
Suppurative lung disease All uncommon
Cystic fibrosis
Post-infective (e.g. adenovirus, pertussis)
Tuberculosis
Ciliary abnormalities
Congenital abnormalities of the respiratory tract
BronchiectasisBronchiectasis
Measles, Pertussis
Tuberculosis
Adenovirus infection type 3,4,7and 21
Immuno deficiency disordersImmuno deficiency disorders
Unusually severe
Recurrent
Unresponsive to conventional treatment
Associated featuresAssociated features
Failure to thrive
GI disease
Skin and soft tissue infections
Family historyFamily history
Severe infections
Deaths
Consanguinity
ImmunodeficienciesImmunodeficiencies
Primary
About 80
Secondary
Malignancy
Immunosuppression
HIV
Primary immunodeficienciesPrimary immunodeficiencies
Defects in Humoral immunity 50%
Combined Tcell and B cell 30%
Defects in Phagocytes 18%
Complement <2%
PrototypesPrototypes
SCID
Bruton’s X linked agammaglobulinemia
Screening testsScreening tests
X Ray chest Thymus
Absolute lymphocyte count
Absolute Neutrophil count
Ultrasound for splenic size
Defects in Humoral systemDefects in Humoral system
Measurement of IgG , A ,M, E
Look at the IgA value if normal it rules out B cell
defects
If IgA is low measure IgG and IgM
IgA values undetected at birth ,rise at 2-3yrs and
reach adult values at 9yrs
Other tests Other tests
Measure isohemagglutinins
Antibodies to type A and B red cell polysaccharide
antigens(IgM)
Measure antibodies to diptheria, tetanus,H.Influ
polyribose phosphate and pneumococcal
antigens(IgG)
IgG subclass 123
Not useful
If agammaglobulinemia is proved Blood B cells
should be enumerated by flow cytometry
T CellsT Cells
Candida skin test
If skin test is positive all Tcell defects are
precluded
T Cell phenotyping
T Cell function
T Cell PhenotypingT Cell Phenotyping
Enumeration of T cell subtypes
Absolute lymphocyte count
Flow cytometry
CD4 Helper T Cells( Cluster of
differentiation ,glycoprotein
Phagocyte cells Phagocyte cells
NBT test
Respiratory burst assay
Cystic FibrosisCystic Fibrosis
Meconium ileus
Failure to thrive
Greasy stools with fat globules on microscopy
Respiratory signs and symptoms proceeding to
suppurative lung disease
Rectal prolapse
Nasal polyps
Tests for Cystic fibrosisTests for Cystic fibrosis
Sweat chloride test
More than 60 meq / lt
Testing for Gene mutations for cystic fibrosis
Disorders of Ciliary functionDisorders of Ciliary function
Microcilia of the respiratory epithelium beats in a
regular coordinated manner
Propelling mucus to oropharynx where it is
swallowed or expectorated
Mucus serves as a physical and chemical barrier
Primary Ciliary DyskinesiaPrimary Ciliary Dyskinesia
1: 16000 to 20000
Autosomal recessive
Undiagnosed
Poor awareness of clinical spectrum
PCDPCD
Abnormal mucociliary clearance
Can present in the neonatal period
Present with tachypnoea,nasal obstruction
and a mucopurulent discharge
PCD Older childPCD Older child
Persistent productive cough
Severe GERD
Atypical asthma
Upper respiratory tract is also involved
Purulent Rhinitis, Sinusitis, Otitis media with
effusion and conductive deafness
Kartagener’s SyndromeKartagener’s Syndrome
PCD + Situs inversus totalis
Diagnosis Diagnosis
High speed digital imaging+ Electron
microscopy of nasal epithelial brush biopsies
Technically difficult
Nasal Nitric Acid is lower in children with PCD
Causes of recurrent or persistent cough
Suppurative lung disease All uncommon
Cystic fibrosis
Post-infective (e.g. adenovirus, pertussis)
Tuberculosis
Ciliary abnormalities
Congenital abnormalities of the respiratory tract
Congenital MalformationsCongenital Malformations
Congenital abnormalities of the airways
Lung parenchyma
Pulmonary vasculature
Sequestrated lung
Bronchial stenosis
Bronchomalacia
Cystic adenomatoid malformation
Esophageal atresia and TEFEsophageal atresia and TEF
Recurrent pneumonias
GE reflux, oesophageal dysmotility and
strictures
Repeated aspiration
INVESTIGATIONSINVESTIGATIONS
InvestigationsInvestigations
X Ray chest
HRCT lung is more sensitive than X ray in
revealing Bronchiectasis
Bronchial wall thickening or inflammation
involving several lobes
Focal changes in cong abnormality ,FB or
bronchial obstruction
Flexible Fibreoptic BronchoscopyFlexible Fibreoptic Bronchoscopy
Cellular specimens
Microbiological specimens
Study of anatomy
Immunological work up
Milk scans
Esophageal ph monitoring
Myths about diet and Resp symptomsMyths about diet and Resp symptoms
Cow’s milk and asthma
Citrus fruits
Chocolate
Tomato
Following facts should be establishedFollowing facts should be established
The time interval between ingestion and development of symptoms
Types of symptoms elicited by ingestion Whether the food has produced similar
symptoms on earlier occasion
Skin testingSkin testing
Negative skin test virtually excludes an IgE form of food allergy
Quantitative measurement of food specific IgE values
Elimination diets followed by food challenges are the only way to establish the diagnosis