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Page 1/Case09/01


PRESENTING FELLOW

Theo Moraes, MD, FRCPC
Chief Pulmonary Fellow, Hospital for Sick Children
Toronto, Ontario, Canada

CASE PRESENTATION

"Just a case of asthma..."

We received a referral in our chest clinic last year for a young boy with asthma. The referral note was short and read, "8 year old with asthma".

– Had a lobectomy in '98.
– Sweat test negative
– TB skin test negative.

"Recently moved from Saskatoon. Well controlled at present but needs respirologist follow-up". Seemed innocent enough.

HISTORY

His history was reviewed in clinic and revealed the following information. He was born at 32 weeks gestation but was not ventilated. In fact, he had a healthy perinatal course.

He was one of triplets. Both his brothers are alive and very healthy with no respiratory complaints. He had a hernia repair at 4 months. He has had problems with growth since 4 months with his height and weight barely tracking the third percentiles. His milestones were a little delayed compared to his brothers.

He was noted to have a few café au lait spots and so was worked up for neurofibromatosis. Mom informed us that these investigations (including head imaging) were all negative.

He first had respiratory complaints at 3 years of age. At this time he presented with cough and wheeze. He received a presumptive diagnosis of asthma. His symptoms were aggravated by viral infections, dust, mold and pollen. He responded acutely to beta 2-agonist treatment but seemed to have chronic symptoms despite the use of inhaled corticosteroids and an anti-leukotriene-receptor antagonist. Mom stated he was treated with anti-reflux medication and did not improve. In addition, she confirmed that he was sweat tested for Cystic Fibrosis and was indeed negative.

Despite his symptoms he had no admissions and no emergency department visits. Interestingly, he had no family history of asthma, eczema or atopy. In addition there were no smokers at home and only one pet; a dog.

The referral note mentioned a lobectomy. Mom told his that when he was 6 years old, in the summer, he had recurrent febrile episodes. A chest x-ray showed right sided collapse. Conservative management with antibiotics and physiotherapy failed to re-expand this lung. Although the history becomes cloudy at this point as no medical notes were available, Mom stated that a foreign body was suspected and he went on to have a bilobectomy (right middle and lower lobes). No foreign body was found in the pathology specimens.


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