with Sabah Iqbal, Children's National, on the Hot Seat
The Case
Parents have tried reflux precautions at home without improvement in symptoms. He had several CXRs done at his PCP due to concern for frequent URI and all have been normal. Because of his frequent URIs, his immunizations have been delayed. He received no immunizations until three days prior to presentation, when he received his two month shots.
The day prior to presentation the pt was seen by his PCP who drew labs and recommended outpatient barium swallow.
On the day of presentation the parents attempted to bring the child in for his scheduled barium swallow but were unable to have it completed due to a scheduling error.
Past medical, surgical history negative except as above. No family history of CF or immunodeficiency. No known sick contacts. The patient is in daycare.
He is now in your ED.
Exam
Vitals: T 37 C HR 140 RR 40 BP 90/69 O2 99% RA
Gen: Non-toxic appearing, well-developed infant.
HEENT: NCAT, pupils reactive, no conjunctival injection or scleral icterus, no rhinorrhea, TMs without injection or exudate.
Chest: Scattered ronchi at bases and mild expiratory wheezes in all lung fields. Intermittent cough, parents report unchanged from prior.
CV: RRR w/o MGR. Pulses 2+ in all four limbs.
Abd: Soft, no tenderness to palpation, no organomegaly.
Ext: Moves all equally, no edema, clubbing or cyanosis.
Skin: No rash, pallor or jaundice
Records from the PCP reveal a negative CXR from the prior day and WBC of 29, diff not performed. CBC and BMP otherwise unremarkable.
Questions for you (click "vote" to see what others said)
More information breaks
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.
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About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series but she is on a well-deserved leave. During July, August, and September guest faculty from Children's National, Inova Fairfax, and Johns Hopkins will serve as case mentors. Cathy Chung, Inova Fairfax, edited this case.
As ED docs, i think we have to look for the big red flags and decide what's truly EMERGENT. A child who has chronic choking with feeds with a negative CXR is sorta underwhelming (from an ED perspective) as long as the child is growing and not having true distress. I would think about fistulas, anatomic abnormalities, aberrant vessels, etc. All can be done as an out-patient (swallow study, pulm vs. ENT). 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.
ReplyDeleteBut 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.
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. My $ would be on an immune workup (starting with QUIGGs), manual smear, chest CT, CF testing, and immuno/pulm consults.
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.
ReplyDeleteThe issue of gagging with feeds seem central to this baby's health problems. So, agree with above about observing feed. 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.
Don't have an explanation for the high wbc count. Doesn't point in a specific direction or narrow the ddx. Given the well appearance of the baby, would not provide antibiotics. So, it would be a piece of information I am holding onto, but not acting on at the time of the visit.
I agree with Dave and Jennifer, although I think I am leaning more towards the TEF as a diagnosis. Another option for eval would be ENT or GI upper endoscopy which may narrow the differential somewhat.
ReplyDeleteAsha
Delete[Caveat from the hot seat attending: This was written at 3:48am. Just saying…]
ReplyDeleteSo… 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…