A 5-month-old infant has had several episodes of wheezing, not clearly related to colds. The pregnancy and delivery were normal; the infant received phototherapy for 1 day after hyperbilirubinemia. He had an episode of otitis media 1 month ago. There is no chronic runny nose or strong family history of asthma. He spits up small amounts of formula several times a day, but otherwise appears well. His growth curve is normal. An examination is unremarkable except for mild wheezing.
Which one of the following is the most likely diagnosis?
Correct Answer E:
Gastroesophageal reflux is a common cause of wheezing in infants. At 5 months of age, most infants no longer spit up several times a day, and this is a major clue that the wheezing may be from the reflux. Also, there is no family history of asthma and the wheezing is not related to infections. Cystic fibrosis is more likely to present with recurrent infections and failure to thrive than with intermittent wheezing.
Which one of the following is true regarding gastroesophageal reflux (GER) in infants and children?
Correct Answer D: Gastroesophageal reflux (GER) is a functional process occurring in a healthy infant. It is common and self-limited, and represents a physiologic process of “spitting up”. GER occurs in the absence of poor weight gain, irritability, cough, pain, or anemia. The majority of infants with GER are thriving.
It is important to consider other systemic disorders, and rule them out when appropriate. Possible causes of spitting up include pyloric stenosis, infections (e.g., gastrointestinal, genitourinary), and metabolic disorders. It is not necessary to perform a diagnostic evaluation prior to starting drug therapy unless a structural defect is highly suspected. GER in infants is usually self-limited and resolves by 1 year of age. Esophageal reflux can be quantified by monitoring esophageal pH (pH probe) or impedance (multichannel intraluminal impedance). However, these studies rarely are useful in evaluating GER or establishing the diagnosis of gastroesophageal reflux disease in infants.
A 6-year-old girl is going to summer camp. Her parents come to your office seeking advice as she had a severe reaction to a honey bee sting two years ago.
Which one of the following recommendations should be given?
Correct Answer B:
Anaphylaxis is an acute, life-threatening, IgE-mediated allergic reaction that occurs in previously sensitized people when they are re-exposed to the sensitizing antigen. Symptoms include stridor, dyspnea, wheezing, and hypotension. Diagnosis is clinical. Bronchospasm and upper airway edema are treated with inhaled or injected β-agonists and sometimes endotracheal intubation. Hypotension requires IV fluids and vasopressors.
Epinephrine is the cornerstone of treatment and should be given immediately. It can be given SC or IM. An self injectable “epinephrine pen’ can be carried by patients with them at all times.
A 5-year-old develops difficulty breathing and facial swelling following subcutaneous injection of an allergen during desensitization therapy.
Which one of the following treatments should be initiated immediately?
Anaphylactic reactions are most commonly caused by drugs (such as penicillin), insect stings, certain foods, and allergy injections (allergen immunotherapy). But they can be caused by any allergen. Like other allergic reactions, an anaphylactic reaction does not usually occur after the first exposure to an allergen but may occur after a subsequent exposure. However, many people do not recall a first exposure. Any allergen that causes an anaphylactic reaction in a person is likely to cause that reaction with subsequent exposures, unless measures are taken to prevent it.
Anaphylactic reactions begin within 1 to 15 minutes of exposure to the allergen. Rarely, reactions begin after 1 hour. The heart beats quickly. The person may feel uneasy and become agitated. Blood pressure may fall, causing fainting. Other symptoms include tingling (pins-and-needles) sensations, itchy and flushed skin, throbbing in the ears, coughing, sneezing, hives, and swelling (angioedema). Breathing may become difficult and wheezing may occur because the windpipe (upper airway) constricts or becomes swollen. An anaphylactic reaction may progress so rapidly that it leads to collapse, cessation of breathing, seizures, and loss of consciousness within 1 to 2 minutes. The reaction may be fatal unless emergency treatment is given immediately.
If an anaphylactic reaction occurs, an epinephrine injection should be given immediately. People who have these reactions should always carry a self-injecting syringe of epinephrine and antihistamine tablets for prompt treatment. Usually, this treatment stops the reaction. Nonetheless, after a severe allergic reaction, such people should go to the hospital emergency department, where they can be closely monitored and treatment can be adjusted as needed.
A 3-year-old toddler with myelomeningocele was hospitalized for a community acquired pneumonia. After a routine urinary catheterization, the patient became tachypneic, tachycardic, wheezy, and hypotensive.
What is the most likely etiology of this patient’s state of shock?
Correct Answer C:
Anaphylactic shock from latex allergy has been associated with myelomeningocele patients. Some authors suggest this may be the result of chronic exposure to latex (i.e., during repeated urinary catheterization). The timing as well as symptoms (wheezing) suggest anaphylaxis.
A to E. Shock, regardless of the etiology, will have similar clinical manifestations (i.e., hypotension and usually tachycardia). Signs of sepsis may include fever or rash or evidence of focal infection, cardiogenic shock may be associated with hepatomegaly, gallop rhythm, or cyanosis, and a clue to hypovolemic shock may come from a history of vomiting, diarrhea, or poor intake. The respiratory symptoms and wheezing should lead to consideration of latex allergy in this case.
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