Case 2: A toddler with a wheeze

16 Oct 2022 11:50 12:10

This is a 1-year-4-month-old boy who presented with 4 episodes of wheezing over the past 6 weeks. He was born term and had infantile eczema. There was a parental history of asthma too. He was previously well until 1-year 2 -months old, when he was admitted for 10 days due to adenovirus pneumonia requiring respiratory support with high flow nasal cannula.  Subsequently, he had another 3 episodes of wheezing over the span of 6 weeks, requiring admissions to hospital. He was diagnosed with multiple trigger wheeze. However, the wheezing and cough persisted despite the use of MDI Flixotide, Montelukast and even MDI Seretide. He was referred to a Paediatric Respiratory physician. On examination, SpO2 was 88% on room air, he had audible wheeze, deep suprasternal recession, generalized rhonchi and crepitations bilaterally. Flexible bronchoscopy revealed severe bronchomalacia of both lower lobes bronchi. HRCT thorax showed patchy ground glass opacities in both lung fields giving a mosaic attenuation pattern. There was also atelectasis in the left lower lobe, and right upper and middle lobes. Bronchial dilatation and peribronchial thickening were seen in the right upper lobe.  He was diagnosed with post adenovirus bronchiolitis obliterans with bronchomalacia and treated with home CPAP, MDI Seretide and Azithromycin. His medical condition improved.

This case highlights that although wheezing is common in this age group and commonly attributed to episodic-viral or multi-trigger wheeze, recurrent or persistent wheezing not responding to inhaled corticosteroids should raise suspicion of other diseases.