Utility of Transbronchial Cryobiopsy via Flexible Bronchoscope in Diagnosis of Isolated Pulmonary LCH: A Case Report.

Flexible bronchoscopes are increasingly being used in diagnostic and therapeutic medicine and have obviated the need for and risks associated with general anesthesia. Here the authors present the case of a 2-y-old girl who was diagnosed with isolated pulmonary Langerhans cell histiocytosis by histopathology; a lung biopsy sample was obtained using a cryoprobe via a flexible bronchoscope. The girl was brought in with complaints of loss of weight, appetite loss, and rapid breathing for the past 2 mo. Examination revealed hypoxia, tachypnea, clubbing with failure to thrive, and bilateral crepitations on auscultation. Imaging studies showed ground-glass opacities with multiple cystic lesions in both lungs. A preliminary diagnosis of LCH was made, and transbronchial cryobiopsy was done via a flexible bronchoscope. Histopathology confirmed the diagnosis with Cluster of differentiation 1a (CD1a) staining. A flexible bronchoscope can be a useful tool for obtaining lung biopsy samples using a cryoprobe in children.

Etiology of Hemoptysis in Children and Adolescents - Multicentric Retrospective Data (2012-2021) From Chennai.

OBJECTIVE: To analyze the etiology of hemoptysis in children and to correlate the severity of bleed with the etiology. METHODS: This retrospective multicentre study reviewed data from inpatient units of four tertiary care public and private sector pediatric hospitals in Tamil Nadu. Methods: Inpatient case records of children (aged 2 month-15 years) treated for hemoptysis at the four institutions between April, 2012 and March, 2021 were identified, after ethical clearance from respective institutions. Data of children with underlying known bleeding disorders like hemophilia or platelet abnormality were excluded from the study. Hemoptysis was categorized as mild, moderate and severe. RESULTS: Of the 73 children who had presented with hemoptysis during the study period, 60 (82.2%) children had mild, 9 (12.3%) had moderate and rest had severe hemoptysis. Idiopathic pulmonary hemorrhage was the most common cause of hemoptysis. The common causes of mild hemoptysis in children were idiopathic pulmonary hemorrhage (n=15, 25%), pulmonary tuberculosis (n=12, 20%) and pneumonia (n=8, 13.3%). Congenital airway anomalies and vascular anomalies were more likely to present with moderate to severe bleed. CONCLUSIONS: Etiology of hemoptysis is broad and categorizing them into mild, moderate and severe may give a clue about the possible etiology, there by restricting to the required investigations.

Laser Treatment of a Tracheal Inflammatory Myofibroblastic Tumor.

BACKGROUND: Inflammatory myofibroblastic tumors of the trachea are rare childhood quasi-neoplastic lesions. CASE CHARACTERISTICS: 7-year-old boy with recurrent episodes of cough, breathing difficulty and wheeze, initially treated as asthma. INTERVENTION: CT chest and flexible bronchoscopy revealed a mass lesion of the trachea, which was excised by diode laser through the ventilating bronchoscope. Histopathology confirmed it as the inflammatory myofibroblastic tumor. MESSAGE: Use of laser ensured complete endotracheal excision of the tumor.

Clinical Characteristics and Associated Congenital Lesions with Tracheomalacia in Infants.

OBJECTIVE: To describe clinical presentation, bronchoscopy findings and associated anomalies in cases of congenital tracheomalacia in infants (age <1y). METHODS: Hospital record review of 88 infants (mean age 8 mo, 57 males) diagnosed as having tracheomalacia by flexible bronchoscopy between 2012 and 2015. RESULTS: The predominant features were wheeze (57.9%), stridor (42.1%), cough (38.6%), pneumonia (29.5%) and collapse (12.5%). On bronchoscopy, malacia was observed in lower half of trachea in 51 (57.9%) infants. Synchronized airway lesions observed were laryngomalacia (30.7%) and bronchomalacia (3.4%). 15 (17%) infants had associated congenital heart disease and 21 (23.8%) required care in intensive care unit. CONCLUSION: Wheeze,stridor and cough are the main symptoms in tracheomalacia. Laryngomalacia and congenital heart diseases are the most common other anomalies associated in these infants.

Pediatric interstitial lung disease.

This study was done to ascertain the symptomatology, clinical features and investigations pertaining to interstitial lung diseases (ILD) in children. The medical records of 16 children admitted over a 4-year period from June 2000 to May 2004 with progressive cough, dyspnea, and chest X-ray/High Resolution Computerized Tomography (HRCT) abnormalities suggesting ILD were retrospectively evaluated. Clinical findings, investigations, chest skiagrams, HRCT, bronchoalveolar lavage (BAL) and lung biopsy reports were analyzed. An acute presentation of symptoms was seen in 4 cases (25%). Velcro crackles were the commonest clinical finding, present in 15 cases (93.8%). Serial X-rays revealed findings suggestive of ILD in 12 cases (75%) and HRCT was diagnostic in 13 cases (86.6%). Spirometry done in 5 cases showed a restrictive ventilatory defect, BAL analysis done in 8 cases demonstrated increased neutrophils and lung biopsy done in 5 cases was consistent with idiopathic pulmonary fibrosis. Mean survival duration of 2 years and 7 months after initial diagnosis was observed.

Airway Diseases Education and Expertise (ADEX ) in Pediatrics: Adaptation for Clinical Practice in India.

JUSTIFICATION: Asthma and allergic rhinitis together are part of the concept of one airway, one disease or united airway disease. The management of allergic airway diseases should address this united concept and manage the issue by educating the patients and their parents and health care providers, along with environmental control measures, pharmacotherapy and immunotherapy. Here, we present recommendations from the module of Airway Diseases Education and Expertise (ADEX) that focused on allergic rhinitis, asthma and sleep disorder breathing as a single entity or Allergic Airway Disease. PROCESS: A working committee was formed by the collaboration of Pediatric Allergy Association of India (PAAI) and Indian Academy of Pediatrics (IAP) Allergy and Applied Immunology chapter to develop a training module on united airway disease. OBJECTIVE: To increase awareness, understanding and acceptance of the concept of United Airway disease and to educate the primary health care providers for children and public health officials, in the management of united airway diseases. RECOMMENDATIONS: Recommendations for diagnosis, management and follow-up of Allergic airway disease are presented in this document. A better compliance by linking education of child, parent, grandparents and other health care providers, and scientific progress by collaboration between practitioners, academicians, researchers and pharmaceutical companies is suggested.

Hypothyroidism with scholastic excellence.

A 9-year-old boy had presented with not gaining adequate height with complaints of constipation from 5 years, lethargy and loss of appetite from past 6 months. He was diagnosed to have hypothyroidism with high thyroid antibody levels. Though he was stunted his neurocognition and scholastic performance was excellent as evidenced by his school rank cards. His physical symptoms had improved after thyroxin supplement.

Value of antibiotic therapy in tuberculin-positive children with parenchymal lung lesions.

BACKGROUND: A tuberculin-positive child with radiological evidence of a parenchymal lung lesion is likely to be treated for tuberculosis by a physician. However, non-tuberculous microbial infections may also cause parenchymal lung lesions. We tried to distinguish tuberculous from non-tuberculous lung lesions by administering a course of antibiotics. METHODS: Three hundred and five tuberculin-positive children with parenchymal lung lesions due to pneumonia, bronchiectasis (cylindrical and reversible) and minor fissure opacification were studied at the Tuberculosis Clinic, Institute of Child Health, Madras. Those with more serious forms of tuberculosis like miliary, cavitary and segmental lesions and with grade III and IV undernutrition were excluded. Three weeks of oral antibiotic therapy, with erythromycin (30 mg/kg/day) and chloramphenicol (50 mg/kg/day) for the first two weeks followed by co-trimoxazole (trimethoprim 6 mg/kg/day and sulphamethoxazole 25 mg/kg/day) for the third week, was given. Chest X-rays were taken before and after antibiotic therapy. RESULTS: Sixty per cent of the children with pneumonia, 57% with bronchiectasis and 62% with minor fissure opacification showed complete radiological clearance. CONCLUSION: In tuberculin-positive children with parenchymal lung lesions radiological clearance was seen in 60% after three weeks of antibiotic therapy indicating that the parenchymal lung lesions were caused by non-tuberculous organisms. Hence a course of antibiotic therapy in these children may have diagnostic value as well as considerable financial, social and therapeutic implications.

Bronchoscopist talks to you.

Fiberoptic bronchoscopy (FBS) is an important entry in the armamentarium of procedures listed in management of respiratory problems. It is a simple and a safe procedure. FBS has a great scope for diagnosis as well as therapy in pediatric respiratory illnesses. This article gives a practical overview of FBS in pediatric practice.

Bronchoalveolar lavage in pediatrics.

Bronchoalveolar lavage is a relatively new technique that is used to study the local cellular, biochemical and immunological changes occurring in the lower respiratory tract. The procedure involves instilling a fixed volume of saline into a lung segment after the flexible fibreoptic bronchoscope is wedged into a distal bronchus. The saline is aspirated back and can be used for microbiological and other studies. Recently, attempts have been made to standardise the procedure in children and obtain data on BAL cellular profile in healthy children. The main indications for BAL are diagnostic, particularly to diagnose unusual infections in immunocompromised children. It is also helpful in the diagnosis of a number on non infectious conditions, based on the cellular profile and other constituents. With the availability of new techniques like flow cytometry, analysis of lymphocyte and other cell subsets has become possible leading to a better understanding of the immunopathogenesis of various respiratory diseases.

Empyema thoracis.

Parapneumonic effusion and empyema thoracis remains a significant source of morbidity in children, though the overall incidence of empyema thoracis has decreased in the past two decades. These conditions pose a dilemma regarding evaluation and treatment for the treating physician. This article discusses the practical strategies in the management of empyema thoracis in children.

Childhood asthma--advances in pathogenesis.

Increase in morbidity and mortality of asthmatics in the world is a cause of concern. Many researchers have described various aspects of etiopathogenesis which has thrown light on the better understanding of asthma. Our experience with nearly 3 lakhs of asthmatic children, over a period of twenty-five years and our studies in Asthma clinic of ICH & HC, Madras generated new ideas to propose a hypothesis on etiopathogenesis of asthma. "Asthma is a disease caused by a specific infective agent in a genetically predisposed individual resulting in altered cellular response initially leading to hyperactive bronchial tree which on exposure to various aggravating factors manifest clinically as recurrent cough, dyspnoea and wheeze". Category of wheezers who manifest asthma is also discussed.

Flexible fiberoptic bronchoscopy.

The value of flexible fiberoptic bronchoscopy in children are increasing day by day, but still underutilized even in many advanced institutions. 630 Fiberoptic bronchoscopy procedures under local anaesthesia were performed for various clinical conditions for diagnosis and therapy. Nasal route is preferred than oral route. Therapeutic indications are more in children than adults. Nearly one third of children with collapse, consolidation have shown radiological clearance after repeated bronchoscopy.

Acute plastic bronchitis.

Plastic bronchitis is a rare disorder characterized by the formation of bronchial cast. The etiology is obscure, though usually associated with conditions like asthma, aspergillosis, pneumonia, cystic fibrosis and cardiac problems.

Flexible fibreoptic bronchoscopy in 582 children--value of route, sedation and local anesthetic.

The value of route, sedation and local anesthetic was studied in 582 children aged 50 days to 12 years who were subjected to flexible fibreoptic bronchoscopy (FFBS) at the Institutes of Child Health, Madras, during January 1989 to July 1993. Pentax 3.5 mm and Olympus 4.9 mm bronchoscopes were used. Bronchoscopy was performed with sedation and/or local anesthetic through nasal/oral route after premedication with atropine. It was successfully carried out through nasal route in 97.4% and only in 40% through oral route. As nasal route proved advantageous, the oral route was abandoned.

Pulmonary cavitatory tuberculosis in children.

This study was undertaken to analyse children with pulmonary cavitatory tuberculosis which is a rare and infectious condition. The pretreatment characteristics, course and response to three different anti-tuberculous regimes in 27 children with cavitary pulmonary lesions registered at the TB Clinic, Institute of Child Health, are described. Male:Female ratio was 1.2:4. Thirty per cent of affected children were below 3 years of age and had predominant lower lobe involvement whereas in older children the upper lobes were affected. Eighty five per cent of children had definite history of contact with an adult with tuberculosis. Tuberculin test was positive in 70% of children. Cavitary lesion were observed in the right lung in 66% of cases. Follow up and surveillance was carried out in 23 children who completed the anti tuberculous treatment. Regimes with isoniazid, rifampicin, pyrazinamide and streptomycin were given to different groups. Response and compliance was also monitored. Eleven out of 23 children had persistence of radiological lesions even after completion of 9 months of therapy. Inclusion of streptomycin with 2 or 3 bactericidal drugs in the intensive phase showed a better response.

Tuberculous disease in a pediatric referral centre: 16 years experience.

Children with evidence of tuberculous disease registered at the TB Clinic, Institute of Child Health, Madras during the years 1977 to 1992 were analyzed. Progressive primary complex, is the commonest thoracic form of tuberculosis while tuberculous meningitis is the commonest extra thoracic form. The overall prevalence of various clinical forms of tuberculosis has decreased over the last 16 years. There is an increasing trend in the prevalence of progressive primary complex among the BCG vaccinated group. The prevalence of pleural effusion, bone tuberculosis and abdominal tuberculosis is almost same over the last 16 years and is more in the BCG non vaccinated children. In tuberculous adenitis there is no significant variation between the two groups. The occurrence of tuberculous meningitis is in the ratio of 1:3 among BCG vaccinated and non-BCG vaccinated children. Though the prevalence of miliary tuberculosis is negligible, it is significantly more in BCG non-vaccinated children. There is a tendency for slight decrease in overall mortality due to tuberculosis in the last 10 years but the mortality due to tuberculous meningitis continues to be the same over the past 16 years.