November 2004
This now 7 year old presented in June with a history of chronic cough, shortness of breath with activity, and abnormal chest x-ray. He presented in March with persistent fevers and was diagnosed at that time with bilateral pneumonia. He returned in May and had a chest x-ray done which showed persistent changes on the left and was put back on antibiotics. At that second visit, he had no fevers.
He had no chest pain but continued to have shortness of breath with activity and also chronic cough. He was seen in Pulmonology
Clinic in June.
Past Medical History unremarkable except of hernia repair. Medications: Montelukast (Singulair) 5 mg q.d., albuterol PRN. Family history remarkable only for asthma in a maternal aunt. He had one brother in good health. Mother had a history of retinitis pigmentosa and obesity. Social History: He was in the first grade. Family lives in a trailer and uses kerosene heat. There were no pets at home. He sleeps in his mother's room on his own bed. His mother does smoke. Review of Systems: Generally unremarkable.
No history of eczema. He has not had previous pneumonias. He has a history of posttussive vomiting with coughing but otherwise, no diarrhea or malabsorption. His development has been normal. He has no history of heart murmurs. He does not pursue any regular exercise. He was on a regular diet. He has been evaluated at Dartmouth by Dr. Casella for evaluation of obesity which was felt primarily social in origin after a normal metabolic workup.
Height
Weight
Respirations
Heart Rate
Saturation on Room Air
Comments:
Physical Examination
75 th percentile for his age
95 th percentile for his age
30/min
117
96%
His exam was normal except for obesity.
Review of outside chest x-rays showed left lower lobe atelectasis and volume loss with compensatory hyperinflation of the right lung.
This had been persistent through May and a follow-up film in clinic showed persistence of left lower lobe atelectasis. There was no hilar adenopathy. He attempted pulmonary function studies which were quite variable in effort with FVC of 90% predicted with FEV
1
79% of predicted and FEF
25-75% of 49% of predicted. Following bronchodilator, he had some improvement but because of the variability in his efforts, this was of doubtful significance.
Because of the persistent LLL atelectasis, he underwent a flexible bronchoscopy. No foreign body was seen but a large tenacious plug was seen in the LLL. This was partially removed by washing and forceps and he was placed on chest physiotherapy. A culture grew only Hemophilus influenzae and he required a course of antibiotics after the bronchoscopy for fever. Cytology showed bronchial cells and pneumocytes present in a background of squamous cells, numerous eosinophils, pulmonary macrophages, mixed
WBC’s and cellular debris. He underwent a second bronchoscopy which showed persistent obstruction by foreign material. Dr. Laurie
Latchaw removed this by rigid bronchoscopy after placing a Foley catheter into the LLL past the plug and extracting it into the bronchoscope. A follow-up chest radiograph showed reexpansion of the LLL.
LLL obstruction secondary to “plastic bronchitis”.
“Plastic bronchitis” is a term for an unusual bronchial obstruction that can occur in a variety of clinical situations. These include children who have undergone surgery for congenital cardiac defects, primarily Fontan repair. These casts are composed primarily of mucin, with no acute inflammatory infiltrate. In these patients the obstruction can be recurring, severe, and lead to life-threatening obstruction. A second group of patients with “plastic bronchitis” have underlying inflammatory and allergic diseases of the lung, such as asthma or fibrosis. Other cases in the literature have developed the casts post-infection, as in this case. The origin of the obstruction in this case isn’t clear and may be due to infection in a patient with underlying asthma but it is doubtful that he would have cleared this thick plug without bronchoscopy.
References: Brogan, TV et al. Plastic bronchitis in children: a case series and review of the medical literature. Ped
Pulmonology 34:482, 2002.
Seer, M et al. Bronchial casts in children: a proposed classification based on nine cases and a review of the literature. Am J Resp Crit Care Med 155:364, 1997.
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November 2004
Bethany (Beth) Ames is 2004 graduate of Dartmouth Medical School. A twin, Beth was born at
Mary Hitchcock Memorial Hospital, and resided in the neonatal intensive care unit for a brief time. Perhaps it was that introduction to the fascinating world of pediatrics which motivated her to pursue her current line of work!
Beth grew up in New Hampshire, and spent her undergraduate years at Brown University where she received her BA. Before entering medical school, Beth spent two years teaching and coaching various sports in boarding schools.
An Academic All American Field Hockey player at Brown, Beth is a sports enthusiast and an avid runner. She and her husband James, an Orthopedic Intern at DHMC, reside in Hanover.
November 29, 2004: Neonatal Critical Care – Hands-on resuscitation skills and didactic lectures; at DHMC in Lebanon.
December 3, 2004: CHaD Currents – Hot Topics in Children’s Health – Newborn Hearing Screening (Christine Rosenwasser,
MD), Common Endocrine Diseases (Kyle Landt, MD), Slipped Capital Femoral Epiphysis (Brian Carney, MD), and Evaluation of
Sports Injuries in Children (Kenneth Weintraub, MD); at D-H Manchester.
March 3-6, 2005: The 15 th Dartmouth Pediatric Conference: Contemporary Issues in Office Pediatrics will focus on
Adolescent Confidentiality, Childhood Obesity, and Childhood Depression, among many other topics. We will return to the
Woodstock Inn and Resort in Woodstock, Vermont.
Pediatric Grand Rounds - Wednesdays at 8AM, Auditorium E at DHMC
November 3: “Self-Regulation in Adolescents with Type I Diabetes” - Dr. Mark Detzer, Dr. Peter Isquith,
Dr. Samuel Casella, Dartmouth Medical School
November 10: “Coming of Age with HIV: Progress, Challenges and Opportunity” - Dr. Cathryn Samples, Harvard
November 17: “Funny-shaped Heads: Craniosynostosis or Not???” - Dr. Susan Durham, DHMC
November 24: “In Honor of Dr. William Boyle: Some Experiences in Resident Education” - Dr. Frederick Lovejoy, Harvard
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Editor: Dr. Rebecca L. Rich, Pediatric Chief Resident
Faculty Advisors: Drs. Norm Berman, Sam Casella, Sara Chaffee, Leslie Fall, Dan Levin, John Modlin, Richard Nordgren,
Dennis Stokes, Jodi Wenger
CHaD Morning Report is intended to provide the reader with interesting and helpful clinical information on a recent case selected from one of CHaD's pediatric inpatient units. Physicians may claim Category 2 credit for this activity. If you would
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November 2004 like to receive this report on a monthly basis, or to unsubscribe, please go to www.dhmc.org/goto/CHaDMorningReport , where current and back issues will be maintained, or call the Connection Line at 1-866-DHMC DOC (346-2362).
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