Case 1: A long history of cough and dyspnea

Abstract

A 10-year-old girl presented with a nine-year history of six to eight upper and lower respiratory tract infections annually, each with a duration of three to six weeks in spite of antibiotic treatment, accompanied with cough, dyspnea and occasional wheezing. She also reported these symptoms during physical exercise, independent of infections. Until now, three pneumonias and multiple bronchitic episodes had been verified. At five years of age, she was diagnosed with bronchial asthma. For two years, treatment consisted of intermittent courses of short-acting beta-agonists and inhaled corticosteroids, before she was switched to a daily combination treatment with long-acting beta-agonists and inhaled corticosteroids (budesonide-formoterol 160 μg/4.5 μg twice daily) plus montelukast 5 mg orally without any breakthrough. A sweat test performed at four years of age was normal, as was a skin prick test to common aeroallergens and measurements of exhaled nitric oxide. Previous lung function tests were reported as a bronchial obstruction with no or only partial bronchodilator response. On presentation, the child was afebrile with normal vital signs, including an oxygen saturation of 97% on room air. A physical examination was unremarkable except for a prolonged expiration on auscultation. A complete blood count was normal and the erythrocyte sedimentation rate was 18 mm/h (0 mm/h to 10 mm/h). Further workup revealed the diagnosis.