Hot Seat #24 Denouement: Coughing with feeds

by Anne O'Connor, Johns Hopkins
with Sabah Iqbal, Children's National, on the Hot Seat

The Case

This is a case of a 5 month-old boy with coughing and gagging with feeds. He missed a scheduled barium swallow study and is now in your emergency room. For a full case presentation, please click here.

Clinical Pearls

Thanks to Dave, Asha, and Jennifer for posting your comments. Click here to read them in full. Here are a few clinical pearls.

"As an ED doc, I would ask, "is there anything else to raise my level of concern?" YES. leukocytosis and bilateral rhonchi. Now i'm concerned for something more systemic." -Dave

"I would definitely WATCH A FEED, because it sometimes help localize the problem, and also differentiates "tiring" which can be a sign of cardiac disease." -Dave

"Another option for eval would be ENT or GI upper endoscopy which may narrow the differential somewhat." -Asha

"I agree that admission for this baby would only be about expediting testing. A thorough conversation with the PCP would obviate the need for admission." -Jennifer

"Sounds like a good age for SCID. I've certainly seen these kids without diarrhea or growth failure, they can present with chronic "vague" infections." -Dave

"My thoughts are categories of anatomic anomalies- esophageal narrowing (web, external compression), TEF (H-type takes longer to dx), physiologic anomalies- GER with microaspiration, dysfunctional swallowing (need dedicated swallow study and not barium swallow), eosinophilic esophagitis; and systemic conditions- CF, hadn't thought of immune deficiencies described above." -Jennifer

Here's how you answered our questions

At this point in your workup, what do you think is the most likely cause of the child's leukocytosis?

In addition to repeating the CBC, of the following what management step would you take next?

A repeat CXR, CBC, UA as well as a respiratory panel were sent from the ER. The CXR was read as normal and the CBC showed WBC 28.2, N 67% E 1% L 32%. Due to the patient’s long drive, radiology agreed to perform the barium swallow, which was read as normal by the resident. The child continued to do well in the ED, with persistent tachypnea without hypoxia. He remained afebrile. 

With the current information, which of the following is the most likely diagnosis?

What is your disposition plan for this patient?

Hot Seat Response
by Sabah Iqbal, Children's National

[Caveat from the hot seat attending: This was written at 3:48am. Just saying…]
So… its August… the lazy last days of summer… which is slow not only in the ER, but also in the back offices where half the attendings are out and the others are scrambling to arrange child care for the these last few weeks between camp and the start of school… so, here I am in the ED and my brain is not working at a frenetic February pace… Its August, for crying out loud, and when I hear hoofbeats, I’m thinking only of horses… and hearing this story, I’m all set to sympathize with mom and dad and offer support and discuss reflux at length until the resident brings me the WBc of 29.
29. 29?! For real?
Hmm…

So, now I’m trying to incorporate the reflux and the URIs and the WBC and the clinical exam: and I think this child probably had chronic reflux and is having micro-aspirations that are causing the wheezing and the frequent “URIs” (I think the kid has so much chronic reflux that he’s more mucosy than most and his coughing and sneezing is being mis-interpreted). “Wait” says my earnest intern-year adult-medicine rotating-resident, “Wait. The chest xray was negative yesterday. I looked at it myself! There's no way this kid has a pneumonia.” Aha. A teaching moment: chest xrays can often lag behind clinical symptoms, I tell my little intern, and shouldn't be relied upon for a diagnosis of PNA – instead, PNA should be a clinical diagnosis and CXR should be only used when there is clinical uncertainty.

So here are my orders for now: Albuterol for the acute bronchospasm. Antibx for the PNA. Can we get a speech and swallow eval in the Ed? (I got one last week – for real!) And let’s get that swallow study done soon, shall we? And I think I’m done: a clinical pearl for the intern and reassurance for mom and dad.

But in the back of my mind, I hold a small worry for a trachea-esophageal fistula – many of those kids present with vague feeding problems and micro-aspirations. So maybe I want a barium swallow done sooner, like today.

So… now, we’re at “more information breaks” – Ahhhh… eosinophils!

Wait. I’m stumped. Eosinophils? Eosinophilis esophagits comes to mind immediately, but it is an illness of older kids… Hmmm… milk protein allergy/intolerance can also present with reflux-type symptoms, increased mucous, and frequent URIs, sometimes, they also have bloody or mucos-y stools. And I just quickly peeked on UpToDate (gotta love that resource in the ED!) and it turns out that mild-protein allergy/intolerance CAN cause an increase WBC with a left shift and INCREASED eos. There you have it, my friends – my final diagnosis is milk protein intolerance – we’ll switch to Neutramigen (which has the milk proteins broken down) and advise that symptoms should improve in 10-14 days (how long it takes for whey and casein to cycle out of the system).

But a nagging thought remains… only a resident read that barium swallow… so before I discharge my cute (I’m assuming he’s cute) little patient, I’m calling to get a final read from the attending…

Hot Seat Denouement
by Anne O'Connor, Johns Hopkins

The patient was given an albuterol inhaler with no improvement in his symptoms. He was able to feed in the ED without emesis and his parents felt comfortable taking him home. He was discharged home with reassurance and close follow-up with his PCP. His pertussis culture came back positive. He was treated with azithromycin as was his brother.

Editors Note: Many tests we send won't come back before we have to make disposition decisions. Examples include the pertussis PCR, gonorrhea/chlamydia, and Lyme titers. Even preliminary radiography reads and EKGs overnight fall into this category. This case highlights  the role of PEM providers in not only zeroing on a diagnosis--which we may not always have--but also figuring out if it's truly an emergency and deciding a disposition based on your risk tolerance. Dave touched on it in his comments about red flags, while Jennifer talked about the role of the PCP in avoiding an admission. Would having results on the PCR immediately have changed the original disposition for this patient? Or in the ED, should we just approach a case as if all tests will be positive?

As for the WBC, which is a lab we do have, here's a a link to a review that suggests extreme leukocytois (much higher than our patient's) may be related to increased risk of mortality and link to a brief commentary on lymphocytosis and pertussis.

The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA. Emily Willner is the faculty advisor on case presentations but is on leave until September. This week's case was guest edited by Cathy Chung, faculty at Fairfax. We welcome your commentary.