Fatal coronary artery anomaly presenting as bronchiolitis

Abstract

Sir: We read with great interest the article from Piastra et al. [3] describing three cases of Anomalous Left Coronary Artery Arising from the Pulmonary Artery (ALCAPA) simulating a bronchiolitis. The article is interesting since it focuses on a congenital anomaly that can easily be misdiagnosed. However, it proposes an approach to avoid error that – in our view – would not be effective. Concerning the implantation of “ ...a training programme to favour limited echocardiography learning by the emergency physicians...”, we consider that the likelihood that such a specialist would be able to diagnose ALCAPA with reliability is unrealistic. Indeed, and as the authors controversially state in their abstract, “...paediatric cardiological evaluation with twodimensional echocardiography may eventually reveal this rare condition, whereas cardiac catheterisation remains the standard means of diagnosis...”. This statement illustrates how difficult it still is to clearly diagnose aberrant origin and course of the coronary artery even by an experienced paediatric cardiologist, and particularly whenever associated with other cardiac lesions simulating a normal physiological scenario [1, 2, 4] Thus, it seems too optimistic to allude that emergency physicians will be skilled enough to do so. Chest X-ray should remain mandatory, and as a matter of fact, a toddler with a suspected non-respiratory wheezing condition and a cardiomegaly, mostly if presenting with signs of circulatory failure, should systematically also have an electrocardiogram with the objective of revealing ischaemic changes evocating the diagnosis as well as echocardiography performed by a paediatric cardiologist, since many other entities other than ALCAPA might induce a dilated hypokynetic cardiomyopathy with similar clinical features: late-diagnosed aortic coarctation, primary cardiomyopathy, myocarditis, sustained arrhythmias, to mention some. The cardiologist would then, based upon the iconographic quality of the echocardiography, decide the need for the cardiac catheterisation. Last, but not least, one should not forget that ALCAPA and a bronchiolitis-like syndrome may co-exist in a same patient, all the more that the first might be unmasked by the last. Eduardo da Cruz, MD Yacine Aggoun, MD Cecile Tissot-Daguette, MD Maurice Beghetti, MD