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