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Dr S.Ramesh 31Oct 2010
Scope of this talk

 The differential diagnosis of rec resp infections


symptoms signs

 How would you work up such a case


Respiratory tract infections

 URTI

 LRTI
URTI

 Common cold

 Tonsillitis

 Pharyngitis

 Sinusitis

 Laryngitis

 ALTB

 Epiglottitis
LRTI

 Pneumonia

 Bronchiolitis

 Bronchitis

 WALRI
Symptoms

 Cough

 Cough with sputum production

 Running nose

 Purulent nasal secretions


Signs

 Stridor

 Rhonchi

 Creps

 Air entry
Incidence of respiratory infections in
the first yr of life

 LRTI 33%

 RSV was the commonest pathogen

 Bronchiolitis accounted for 60% of these


episodes
 'urphy in a 11 yr community study peak incidence
in LRTI at the end of first year

 Jokinen found an incidence of radiologically


proven pneumonia in 36 per 1000 children below
5yrs and 16/1000 between 5-14yrs
 Hospitalisation for pneumonia 4/1000/yr from 1-15yr

 5 times higher in children below 2yrs

 10% of 2900 children admitted with pneumonia had

two or more episodes


:actors influencing the incidence of LRTI

 Age

 Sex

 Prematurity

 Large family
Causes of recurrent or persistent resp signs
and symptoms
 Recurrent µnormal¶ infections V 

 Asthma V 

 Prolonged infection (  . pertussis, mycoplasma, RSV)





 Cigarette smoking (passive/active)




 Habit or psychogenic cough




 Idiopathic

Differential diagnosis of
recurrent 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
Asthma

 'ost children with recurrent chest infections or

a persistent cough will be shown to have

undiagnosed asthma

 Cough variant asthma


Xuestions to ask in suspected cough
variant asthma

 Trigger factors for URTI exercise, cold exposure


to pets

 :amily history of atopy

 Whether to give a trial of bronchodilators or not

 Diagnosis may be difficult under 3 yrs


Post infective cough

 Cough can persist for 2-6 months

 B.Pertussis / ' Pneumoniae

 Hyperactive cough receptors


Post infective recurrent wheeze

 WALRI

 Post Bronchiolitis syndrome


Causes of recurrent or persistent cough
 Aspiration ¢

 †astro-oesophageal reflux ¢

 Incoordinate swallowing ¢

 Intrabronchial foreign body ¢

 'ediastinal or pulmonary tumours V  


Inhaled foreign body

 Peanuts ³Only a nut gives nuts to his child´

 Air entry
K K |K

         


     
   
 
         
 
Chronic suppurative lung disease

Cough with sputum production


Causes of recurrent or persistent cough

 Suppurative lung disease K  

w Cystic fibrosis

w Post-infective (  . adenovirus, pertussis)

w Tuberculosis

w Ciliary abnormalities

w Congenital abnormalities of the respiratory tract


Bronchiectasis

 'easles, Pertussis

 Tuberculosis

 Adenovirus infection type 3,4,7and 21


Immuno deficiency disorders

 Unusually severe

 Recurrent

 Unresponsive to conventional treatment


Associated features

 :ailure to thrive

 †I disease

 Skin and soft tissue infections


:amily history

 Severe infections

 Deaths

 Consanguinity
Immunodeficiencies

Primary

w About 80

Secondary

w 'alignancy

w Immunosuppression

w HIV
Primary immunodeficiencies

 Defects in Humoral immunity 50%

 Combined Tcell and B cell 30%

 Defects in Phagocytes 18%

 Complement <2%
Prototypes

 SCID

 Bruton¶s X linked agammaglobulinemia


   

 |  




 K  
    

 K      

     


Defects in Humoral system

 'easurement of Ig† , A ,', E

 Look at the IgA value if normal it rules out B cell


defects

 If IgA is low measure Ig† and Ig'

 IgA values undetected at birth ,rise at 2-3yrs and


reach adult values at 9yrs
Other tests

 'easure isohemagglutinins

 Antibodies to type A and B red cell


polysaccharide antigens(Ig')

 'easure antibodies to diptheria, tetanus,H.Influ


polyribose phosphate and pneumococcal
antigens(Ig†)
 Ig† subclass 123

 Not useful

 If agammaglobulinemia is proved Blood B cells


should be enumerated by flow cytometry
T Cells

 Candida skin test

 If skin test is positive all Tcell defects are


precluded

 T Cell phenotyping

 T Cell function
T Cell Phenotyping

 Enumeration of T cell subtypes

 Absolute lymphocyte count

 :low cytometry

 CD4 Helper T Cells( Cluster of differentiation


,glycoprotein
Phagocyte cells

 NBT test

 Respiratory burst assay


Cystic :ibrosis

 'econium ileus

 :ailure to thrive

 †reasy stools with fat globules on microscopy

 Respiratory signs and symptoms proceeding to


suppurative lung disease

 Rectal prolapse

 Nasal polyps
Tests for Cystic fibrosis

 Sweat chloride test

 'ore than 60 meq / lt

 Testing for †ene mutations for cystic fibrosis


Disorders of Ciliary function

 'icrocilia of the respiratory epithelium beats in a


regular coordinated manner

 Propelling mucus to oropharynx where it is


swallowed or expectorated

 'ucus serves as a physical and chemical barrier


Primary Ciliary Dyskinesia

 1: 16000 to 20000

 Autosomal recessive

 Undiagnosed

 Poor awareness of clinical spectrum


PCD

 Abnormal mucociliary clearance

 Can present in the neonatal period

 Present with tachypnoea,nasal obstruction


and a mucopurulent discharge
PCD Older child

 Persistent productive cough

 Severe †ERD

 Atypical asthma

 Upper respiratory tract is also involved

 Purulent Rhinitis, Sinusitis, Otitis media with


effusion and conductive deafness
`artagener¶s Syndrome

 PCD + Situs inversus totalis


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 K  

w Cystic fibrosis

w Post-infective (  . adenovirus, pertussis)

w Tuberculosis

w Ciliary abnormalities

w Congenital abnormalities of the respiratory tract


Congenital 'alformations

 Congenital abnormalities of the airways

 Lung parenchyma

 Pulmonary vasculature
 Sequestrated lung

 Bronchial stenosis

 Bronchomalacia

 Cystic adenomatoid malformation


Esophageal atresia and TE:

 Recurrent pneumonias

 †E reflux, oesophageal dysmotility and


strictures

 Repeated aspiration
!"K#
Investigations

 X Ray chest

 HRCT lung is more sensitive than X ray in


revealing Bronchiectasis
 Bronchial wall thickening or inflammation
involving several lobes

 :ocal changes in cong abnormality ,:B or


bronchial obstruction
:lexible :ibreoptic Bronchoscopy

 Cellular specimens

 'icrobiological specimens

 Study of anatomy
 Sweat chlorides

 Standard Diagnostic test for C:

 C: gene mutation studies


 

    $
 'ilk scans

 Esophageal ph monitoring
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