Reviewer: S. Randhawa, M.D.
A 9-year-old African American girl with asthma diagnosed at age 15 months, and with a history of allergic rhinitis and atopic dermatitis is referred for evaluation. The atopic dermatitis has improved with age. She now has symptoms mostly during the winter. Her rhinitis is better controlled with the use of intranasal steroid, however her asthma has proved challenging to control. She has been diagnosed with asthma at age 15 months and she has been treated with inhaled steroids for the last several years, including Advair 115/21 for the last year. She still needs to use albuterol 3-4 times per day, including before exercise. Her symptoms are manifested by chest tightness and cough, not much wheezing, but definitely the chest tightness is one of her predominant symptoms. The triggers of her symptoms include infections, exercise and changes in weather. She has symptoms once to twice per week, including during the night once to twice a week and the last course of oral steroids was 5 months ago. She was never hospitalized with asthma and has no emergency room visits. She had spirometry done 5 months ago which showed FEV1 of 74%, which actually decreased by 10% with bronchodilator use. She had ImmunoCAP specific IgE testing for allergens and it was all negative apart from a positive to one of the trees, oak. She also complains of congestion and itchy eyes which are worse during the spring and fall, and snoring at night. She was evaluated with a sleep study which showed mild sleep apnea. They do not report a history of recurrent skin infections. She was treated with for a respiratory infection earlier this year with antibiotics and chest x-ray done years ago was negative.
Past medical history is positive for asthma, rhinitis and atopic dermatitis. Past surgical history is negative. She has no known drug allergies.
Family history is positive for mother with allergic rhinitis, sister with asthma and allergic rhinitis.
On social history, she is exposed to second-hand smoke from a neighbor in the apartment complex and also her father is a smoker. They have no pets at home. There is no carpet and no visible mold in the house.
On birth history, she was born via C-section. She was born at term and she was breast fed for a short period of time.
Her current outpatient prescriptions include Advair 115/21 one inhalation b.i.d. with Aero-Chamber, albuterol p.r.n., Pataday eye drops, Zyrtec and Nasacort one spray in each nostril daily.
HEENT examination showed some dry discharge in both nostrils and boggy turbinates which are mildly erythematous. Chest was clear to auscultation bilaterally. Cardiovascular system showed clear S1, S2. Abdomen was soft, nontender and nondistended. Extremities showed no clubbing, cyanosis or edema and skin showed mild lesions of atopic dermatitis on upper extremities.
Procedures: Skin prick test and spirometry. The skin prick test was negative to cat, dog, cockroach, dust mite, trees, grasses, weeds, ragweed and mold and had a good reaction to histamine. The size of the wheel was 6 x 6 mm. She had spirometry which initially showed FVC of 79% and FEV1 of 66%. FEV1 improved significantly with the administration of nebulized albuterol. There was an improvement of 19% in FEV1 from 1.47 L to 1.77 L, so the bronchodilation test was positive.
What is the most likely diagnosis?
This is a child with severe asthma, including night symptoms with inadequate response to Advair at the dose of 115/21. She does not provide a certain history of reflux disease, although she has some night cough, but no heartburn or metallic taste in her mouth. She has not been on Singulair in the past and we discussed the possibility of vitamin D deficiency or insufficiency in patients with severe asthma, and other comorbidities. She is not a likely candidate for the diagnosis of vocal cord dysfunction (VCD) as she does not have symptoms of VCD (voice change, etc.) during her asthma attacks. Her rhinitis is most likely nonallergic with negative skin prick test today and negative specific IgE 7 years ago, apart from the mild sensitization to oak. There is no history of food allergy. She has mild eczema which is easy to control with moisturizers.
What treatment approach would you suggest?
Considering that even with the moderate dose of Advair she did not have full control of her symptoms in the past and she needed to use albuterol 3-4 times a day, I would suggest a trial of a different combination of inhaled steroids and long-term beta agonist, namely Symbicort at a dose of 160/4.5 two puffs twice a day with an AeroChamber. The formoterol in Symbicort has some short-acting and long-acting bronchodilator effects and she may have better control of symptoms with that. Also, I would recommend adding Singulair 5 mg chewable tablet to her regimen and taking a multivitamin for the vitamin D component, 1 tablet p.o. daily. Considering that her skin prick was negative, I would probably discontinue cetirizine at this point. She, however, can continue to use the Nasacort at a dose of 1 spray each nostril twice a day to control her nasal inflammation, which is most likely due to nonallergic rhinitis at this point. I suggested followup in approximately 1-2 months for repeat spirometry to verify that these changes in her treatment have the desirable effect. If there is a suspicion for GERD, we can consider a PPI addition to the therapy at that point.
It is very important for her not be exposed to tobacco smoke. A 2012 study showed that when household members smoked, children had up to 70% higher risk of wheezing through age 4 (http://goo.gl/bTTyy).
Severe asthma - differential diagnosis and management (click to enlarge the image).
Worldwide, 40% of children, 33% of male non-smokers, 35% of female non-smokers are exposed to second-hand smoke http://goo.gl/xFGef