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.

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.

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.

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.

Age, nutritional status and INH acetylator status affect pharmacokinetics of anti-tuberculosis drugs in children.

SETTING: The currently recommended dosages of rifampicin (RMP), isoniazid (INH), pyrazinamide (PZA) and ethambutol in children are extrapolated from adult pharmacokinetic studies, and have not been adequately evaluated in children. OBJECTIVE: To describe the pharmacokinetics of RMP, INH and PZA given thrice weekly in children with tuberculosis (TB), and to relate pharmacokinetics to treatment outcomes. METHODS: Eighty-four human immunodeficiency virus negative children with TB aged 1-12 years in Chennai and Madurai, India, were recruited. Phenotypic INH acetylator status was determined. Nutritional status was assessed using Z scores. During the intensive phase of anti-tuberculosis treatment, a complete pharmacokinetic study was performed after directly observed administration of drugs. At 2 and 6 months, drug levels were measured 2 h post-dose. Drug concentrations were measured using high performance liquid chromatography and pharmacokinetic variables were calculated. Multivariable regression analysis was performed to explore factors impacting drug levels and treatment outcomes. RESULTS AND CONCLUSIONS: Children aged <3 years had significantly lower RMP, INH and PZA concentrations than older children, and 90% of all children had sub-therapeutic RMP Cmax (<8 µg/ml). Age, nutritional status and INH acetylator status influenced drug levels. Peak RMP and INH concentrations were important determinants of treatment outcome. Recommendations for anti-tuberculosis treatment in children should take these factors into consideration.

Indications and outcome of flexible bronchoscopy in neonates.

OBJECTIVE: To analyse the indications, safety and outcome of flexible fiberoptic bronchoscopy (FOB) in neonates. METHODS: This descriptive study was conducted in Level III neonatal unit (ICH, Chennai) and included 84 neonates with various respiratory problems admitted over a 3 y period. RESULTS: The indications included stridor (18%), persistent radiological abnormalities (44%), unexplained wheeze/respiratory distress (21%) and others (17%). The mean age and weight were 25 d and 2.82 kg respectively. Bronchoscopy detected various anomalies like upper airway anomalies (10.7%), lower airway malacia (21%), synchronous airway malacias (19%) and miscellaneous anatomical abnormalities (18%). Bronchoalveolar lavage was done in 62% with microbiological yield in 54% cases.FOB helped in the revision of diagnosis in 57%. Resolution of atelectasis was observed in 13.5% cases. Except for transient hypoxemia in 2 neonates, no other complication was encountered. CONCLUSIONS: Flexible bronchoscopy is safe and useful both as diagnostic and therapeutic tool in neonates with respiratory problems.

Treatment of childhood tuberculosis.

The aim of tuberculosis treatment is to cure the individual patient with antituberculosis drugs (ATT) in a short time without emergence of drug resistance. The anti tuberculosis drugs are selected in a combination to attack all the subpopulations of tubercle bacilli with first line drugs which include isoniazid, rifampicin, pyrazinamide, and ethambutol. Intermittent ATT regimens have been documented to be as effective as daily regimen. World Health Organization (WHO) has suggested a category based treatment of tuberculosis given in two phases, intensive phase and continuation phase. As per WHO, Revised National Tuberculosis Control Programme (RNTCP) recommends directly observed therapy short course strategy (DOTS) for the treatment of both adult and pediatric tuberculosis. In DOTS the patient is asked to swallow ATT under the direct observation of health personnel. Drug dosage for daily and intermittent therapy varies. To simplify the prescription, fixed drug combination (FDC) and patient-wise boxes (PWB) are available under RNTCP, free of cost. Each patient's management plan should be individualized to incorporate measures that facilitate adherence. The knowledge of drug resistant tuberculosis, HIV-related tuberculosis, and latent tuberculosis infection are the areas that need to be updated. Private practioners may play a significant role by referring the children with tuberculosis to the DOTS centers early which will not only benefit the affected family but also the society.

Tracheobronchomalacia presenting as infantile wheeze.

We report six months old infant with a history of recurrent wheeze, admitted for foreign body aspiration like presentation, where fibreoptic bronchoscopy revealed the diagnosis of tracheobronchomalacia.

Lower airway anomalies in infants with laryngomalacia.

OBJECTIVE: To study the prevalence of associated airway anomalies in infants presenting with moderate to severe laryngomalacia. METHODS: Eighty three (83) symptomatic infants with recurrent respiratory symptoms including wheeze and cough diagnosed as moderate to severe laryngomalacia based on their clinical and direct laryngoscopic findings were subjected to fiberoptic bronchoscopy (FOB) during the period March 2007 to February 2009 in the Department of Pulmonology, Institute of Child Health and Hospital for Children, Chennai, India. Analysis of the clinical features, radiological findings and associated lower airway anomalies by FOB was done. RESULTS: Lower airway anomalies were demonstrated in 40 (48%) infants of the study population. Tracheomalacia was the most common lower airway anomaly 24 (29%) followed by bronchomalacia 8(10%) and tracheobronchomalacia 6 (7%). (4:1:1). CONCLUSION: Infants with moderate and severe laryngomalacia should be evaluated with flexible fibreoptic bronchoscopy to rule out associated lower airway lesions.

Fiberoptic bronchoscopy in unresolved atelectasis in infants.

This retrospective analysis documents the usefulness of fiberoptic bronchoscopy in finding the etiology of 56 cases of unresolved atelectasis in infancy, over a two year period (June 2005 to May 2007). Fiberoptic bronchoscopy identified the etiology leading to a revised diagnosis and change in management strategy in 38 (67.8%) cases, which included congenital airway anomalies (46.4%), inflammatory changes (10.7%), mucus plugs (28.5%), hypoplasia (4%), endobronchial granulation tissue (3.5%) and foreign body (3.5%). Fiberoptic bronchoscopy plays an important role in diagnostic work up of infants with unresolved atelectasis.