Un paciente con... Tos / A patient with... Cough

El 3,3-10% de la población presenta tos crónica, siendo un motivo frecuente de consulta en Atención Primaria (AP). Se plantea el caso de una mujer de 61 años con tos de 3 meses de evolución. La sospecha diagnóstica es de fibrosis pulmonar en el contexto de una posible artritis reumatoide versus neumonía intersticial descamativa secundaria a aripiprazol. El caso clínico sirve de reflexión sobre la importancia de una buena anamnesis en AP, así como un correcto uso de las pruebas complementarias para valorar causas menos frecuentes de un síntoma común. Debe desarrollarse una capacidad inductiva y valorar el contexto del síntoma guía para confeccionar un diagnóstico sindrómico lo más acertado posible, lo cual es muy valioso en este nivel asistencial. (AU)

Chronic cough is a common reason for consultation in primary care (prevalence approximately 3.3% to 10.0%). We report a case of a 61-year-old woman with a three-month history of cough. The most accurate diagnosis is pulmonary fibrosis in the context of rheumatoid arthritis versus desquamative interstitial pneumonia secondary to aripiprazole. This case study serves as a reflection on the importance of a good history in primary care. Moreover, it is relevant to correctly use complementary tests. It is especially important to make a good syndromic diagnosis and evaluate the context of the patient in front of us. (AU)

Altered functional connectivity of the nucleus tractus solitarii in patients with chronic cough after lung surgery: an rs-fMRI study.

BACKGROUND: To explore the altered functional connectivity (FC) of the nucleus tractus solitarii (NTS) in patients with chronic cough after lung surgery using resting-state functional magnetic resonance imaging (rs-fMRI), and the association between abnormal FC and clinical scale scores. METHODS: A total of 22 patients with chronic cough after lung surgery and 22 healthy controls were included. Visual analog scale (VAS), Mandarin Chinese version of the Leicester Cough Questionnaire (LCQ-MC), and Hamilton anxiety rating scale (HAMA) scores were assessed, and rs-fMRI data were collected. The FC analysis was performed using the NTS as the seed point, and FC values with all voxels in the whole brain were calculated. A two-sample t-test was used to compare FC differences between the two groups. The FC values of brain regions with differences were extracted and correlated with clinical scale scores. RESULTS: In comparison to healthy controls, FC values in the NTS and anterior cingulate cortex(ACC) were reduced in patients with chronic cough after lung surgery (GRF correction, p-voxel < 0.005, p-cluster < 0.05) which were positively correlated with LCQ-MC scores (r = 0.534, p = 0.011), but with VAS (r = -0.500, p = 0.018), HAMA (r = -0.713, p < 0.001) scores were negatively correlated. CONCLUSIONS: Reduced FC of the NTS with ACC may be associated with cough hypersensitivity and may contribute to anxiety in patients with chronic cough after lung surgery.

CT airway remodelling and chronic cough.

RATIONALE: Structural airway changes related to chronic cough (CC) are described in the literature, but so far reported data are rare and non-conclusive. Furthermore, they derive mainly from cohorts with small sample sizes. Advanced CT imaging not only allows airway abnormalities to be quantified, but also to count the number of visible airways. The current study evaluates these airway abnormalities in CC and assesses the contribution of CC in addition to CT findings on the progression of airflow limitation, defined as a decline in forced expiratory volume in 1 s (FEV1) over time. METHODS: A total of 1183 males and females aged ≥40 years with thoracic CT scans and valid spirometry from Canadian Obstructive Lung Disease, a Canadian multicentre, population-based study has been included in this analysis. Participants were stratified into 286 never-smokers, 297 ever-smokers with normal lung function and 600 with chronic obstructive pulmonary disease (COPD) of different severity grades. Imaging parameters analyses included total airway count (TAC), airway wall thickness, emphysema as well as parameters for functional small airway disease quantification. RESULTS: Irrespective of COPD presence, CC was not related to specific airway and lung structure features. Independent of TAC and emphysema score, CC was highly associated with FEV1 decline over time in the entire study population, particularly in ever-smokers (p<0.0001). CONCLUSION: The absence of specific structural CT features independently from COPD presence indicate that other underlying mechanisms are contributing to the symptomatology of CC. On top of derived CT parameters, CC seems to be independently associated with FEV1 decline. TRIAL REGISTRATION NUMBER: NCT00920348.

A novel multimodal fusion framework for early diagnosis and accurate classification of COVID-19 patients using X-ray images and speech signal processing techniques.

BACKGROUND AND OBJECTIVE: COVID-19 outbreak has become one of the most challenging problems for human being. It is a communicable disease caused by a new coronavirus strain, which infected over 375 million people already and caused almost 6 million deaths. This paper aims to develop and design a framework for early diagnosis and fast classification of COVID-19 symptoms using multimodal Deep Learning techniques. METHODS: we collected chest X-ray and cough sample data from open source datasets, Cohen and datasets and local hospitals. The features are extracted from the chest X-ray images are extracted from chest X-ray datasets. We also used cough audio datasets from Coswara project and local hospitals. The publicly available Coughvid DetectNow and Virufy datasets are used to evaluate COVID-19 detection based on speech sounds, respiratory, and cough. The collected audio data comprises slow and fast breathing, shallow and deep coughing, spoken digits, and phonation of sustained vowels. Gender, geographical location, age, preexisting medical conditions, and current health status (COVID-19 and Non-COVID-19) are recorded. RESULTS: The proposed framework uses the selection algorithm of the pre-trained network to determine the best fusion model characterized by the pre-trained chest X-ray and cough models. Third, deep chest X-ray fusion by discriminant correlation analysis is used to fuse discriminatory features from the two models. The proposed framework achieved recognition accuracy, specificity, and sensitivity of 98.91%, 96.25%, and 97.69%, respectively. With the fusion method we obtained 94.99% accuracy. CONCLUSION: This paper examines the effectiveness of well-known ML architectures on a joint collection of chest-X-rays and cough samples for early classification of COVID-19. It shows that existing methods can effectively used for diagnosis and suggesting that the fusion learning paradigm could be a crucial asset in diagnosing future unknown illnesses. The proposed framework supports health informatics basis on early diagnosis, clinical decision support, and accurate prediction.

Differences in the association of cough and other clinical signs with ultrasonographic lung consolidation in dairy, veal, and beef calves.

Bovine respiratory disease (BRD) continues to be a leading cause of economic loss, hampered animal welfare, and intensive antimicrobial use in cattle operations worldwide. Reduction of antimicrobial use is hindered because it is still unclear which clinical signs are best monitored to reliably detect pneumonia. Also, these clinical signs may vary according to age and between breeds. The objective of this cross-sectional study was to identify clinical signs associated with ultrasound-confirmed pneumonia (lung consolidation ≥1 cm depth) pre- and postweaning in different production types (dairy, beef, and veal) and breeds. A total of 956 calves (70% Holstein-Friesian dairy and 30% Belgian Blue beef) from 84 herds were clinically examined using 24 parameters, scored using the Wisconsin and California BRD clinical scoring systems and subjected to thoracic ultrasonography. Of the calves, 42.8% and 19.5% had a lung consolidation ≥1 cm and ≥3 cm, respectively. Cough, both spontaneous and induced, was the only and best-performing clinical sign statistically associated with lung consolidation in all production types. Fever (rectal temperature ≥39.4°C) was the second most promising factor, being significant in beef and veal calves but not in dairy calves. Postweaning, none of the clinical signs studied were statistically associated with pneumonia, with the exception of cough in dairy calves. Spontaneous or induced cough as a single clinical sign outperformed any combination of clinical signs, including the Wisconsin and California respiratory disease scoring systems, but sensitivity remained low. This information can be useful to select appropriate clinical signs for continuous monitoring in precision livestock applications, targeted to a given breed and age. As a cross-sectional measurement, diagnostic accuracy of spontaneous cough (accuracy = 65.1%, sensitivity = 37.4%, specificity = 85.7%) is too low to be used as a criterion to select animals with pneumonia for antimicrobial treatment. At the group level, cough monitoring holds potential as an early warning sign, after which lung ultrasonography should follow.

Diagnóstico tardío de cuerpos extraños en vía aérea en pediatría en el ospital de Especialidades Carlos Andrade Marín / Late diagnosis of foreign bodies in pediatric airway in the Carlos Andrade Marín Specialties Hospital

La aspiración de cuerpos extraños es una de las principales causas de ingreso a urgencias y de morbi-mortalidad en Ecuador en pacientes pediátricos. El diagnóstico suele ser tardío, por falta de interés de los cuidadores, o por errores en la valoración. Es importante detectar el cuadro a tiempo, para evitar complicaciones. OBJETIVO. Demostrar la necesidad de un diagnóstico acertado ante la alta sospecha en un cuadro dudoso de aspiración de cuerpo extraño. SERIE DE CASOS. Evaluación de cuatro pacientes de ambos sexos, de entre 11 meses a 15 años de edad con antecedente de ingesta de cuerpo extraño, atendidos en la Unidad Técnica de Cirugía Pediátrica, del Hospital de Especialidades Carlos Andrade Marín, durante el periodo 2019-2020. Se realizó la extracción exitosa mediante broncoscopia rígida en tres de ellos. DISCUSIÓN. La mayoría de pacientes con aspiración de cuerpo extraño suelen ser menores de 5 años de edad, en contraste con éste estudio, donde sólo un paciente estuvo dentro de este rango, y el resto fueron escolares y adolescentes. El cuerpo extraño más común es de origen orgánico; el 50% de los casos observados fue de origen inorgánico. CONCLUSIÓN. El diagnóstico de aspiración de cuerpo extraño se condiciona a la obtención completa de datos sobre la Historia Clínica; requiere una valoración rápida y manejo adecuado por emergencias.

INTRODUCTION. Foreign body aspiration is one of the main causes of emergency room admissions and morbidity and mortality in pediatric patients in Ecuador. Diagnosis is usually late, due to lack of interest of caregivers, or due to errors in the assessment. It is important to detect the condition in time to avoid complications. OBJECTIVE. To demonstrate the need for an accurate diagnosis in the presence of high suspicion in a doubtful picture of foreign body aspiration. CASE SERIES. Evaluation of four patients of both sexes, between 11 months and 15 years of age with a history of foreign body ingestion, attended at the Pediatric Surgery Technical Unit of the Carlos Andrade Marin Specialties Hospital, during 2019-2020 period. Successful extraction by rigid bronchoscopy was performed in three of them. DISCUSSION. Most patients with foreign body aspiration are usually under 5 years of age, in contrast to this study, where only one patient was within this range, and the rest were schoolchildren and adolescents. The most common foreign body is of organic origin; 50% of the cases observed were of inorganic origin. CONCLUSION. The diagnosis of foreign body aspiration is conditioned to the complete collection of data on the Clinical History; it requires a rapid assessment and appropriate emergency management.

ACR Appropriateness Criteria® Chronic Cough.

Chronic cough is defined by a duration lasting at least 8 weeks. The most common causes of chronic cough include smoking-related lung disease, upper airway cough syndrome, asthma, gastroesophageal reflux disease, and nonasthmatic eosinophilic bronchitis. The etiology of chronic cough in some patients may be difficult to localize to an isolated source and is often multifactorial. The complex pathophysiology, clinical presentation, and variable manifestations of chronic cough underscore the challenges faced by clinicians in the evaluation and management of these patients. Imaging plays a role in the initial evaluation, although there is a lack of high-quality evidence guiding which modalities are useful and at what point in time the clinical evaluation should be performed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Evaluation of bronchial narrowing in coughing dogs with heart murmurs using computed tomography.

BACKGROUND: The origin of cough in dogs with heart murmurs is controversial, because the cough could be primary cardiac (eg, pulmonary edema, bronchi compression by left-sided cardiomegaly) or respiratory (eg, bronchomalacia, other bronchial or bronchiolar disease, interstitial lung disease) in origin. HYPOTHESIS/OBJECTIVES: To study the association between left atrium (LA) dilatation and cardiomegaly and bronchial narrowing in coughing dogs with heart murmurs using computed tomography (CT). ANIMALS: Twenty-one client-owned coughing dogs with heart murmurs and 14 historical control dogs. METHODS: Dogs with cough and murmur were prospectively recruited over 4 months. Cervical and thoracic radiography, echocardiography, and thoracic CT were performed in enrolled dogs. Control dogs, with no disease on thoracic CT and no records of heart murmur and coughing, were gathered from the institution's computerized database. Degree of bronchial narrowing was assessed using the bronchial-to-aorta (Ao) ratio, measured by 3 radiologists blinded to the clinical findings. After identifying bronchi that were significantly narrowed in dogs with murmur compared to controls, the relationship between degree of narrowing and LA/Ao ratio (measured echocardiographically) and vertebral heart scale (VHS) measured radiographically was studied in dogs with murmur using mixed-effects regression. RESULT: Significant narrowing was identified for all left-sided bronchi and the right principal, middle, and caudal bronchi in the coughing dogs, compared with controls. Increasing LA size and VHS were significantly inversely associated with diameter for all left-sided and right-sided bronchi indicated above. CONCLUSION AND CLINICAL IMPORTANCE: Results indicate an association between LA enlargement and cardiomegaly and bronchial narrowing and support heart size-associated exacerbation of cough in dogs with murmurs.

A 56-Year-Old Man With Chronic Cough, Hemoptysis, and a Left Lower Lobe Infiltrate.

CASE PRESENTATION: A 56-year-old man presented to the lung nodule clinic with abnormal chest imaging prompted by a chronic cough and hemoptysis. Approximately 2.5 years earlier, while kneeling beside his car fixing a flat tire, he fell backwards while holding the tire cap in his mouth, causing him to inhale sharply and aspirate the cap. He immediately developed an intractable cough productive of flecks of blood. He presented to an emergency room but left before being seen because of a long wait time and his lack of health-care insurance. He self-medicated for severe cough and chest discomfort with codeine, eventually developing a dependency. Approximately 3 weeks after aspirating the tire cap, his cough became productive, and he developed fever and chills. His symptoms improved transiently with antibiotics and additional narcotics. Ultimately, his chronic cough with intermittent hemoptysis affected his ability to work, and 30 months later he sought medical attention and was diagnosed with pneumonia and reactive airway disease. He was prescribed doxycycline, steroids, inhaled albuterol, and dextromethorphan, with initial improvement, but his symptoms recurred multiple times despite quitting smoking, leading to repeated medication courses.

Opsoclonus-myoclonus syndrome, a post-infectious neurologic complication of COVID-19: case series and review of literature.

Opsoclonus-myoclonus-ataxia syndrome is a heterogeneous constellation of symptoms ranging from full combination of these three neurological findings to varying degrees of isolated individual sign. Since the emergence of coronavirus disease 2019 (COVID-19), neurological symptoms, syndromes, and complications associated with this multi-organ viral infection have been reported and the various aspects of neurological involvement are increasingly uncovered. As a neuro-inflammatory disorder, one would expect to observe opsoclonus-myoclonus syndrome after a prevalent viral infection in a pandemic scale, as it has been the case for many other neuro-inflammatory syndromes. We report seven cases of opsoclonus-myoclonus syndrome presumably parainfectious in nature and discuss their phenomenology, their possible pathophysiological relationship to COVID-19, and diagnostic and treatment strategy in each case. Finally, we review the relevant data in the literature regarding the opsoclonus-myoclonus syndrome and possible similar cases associated with COVID-19 and its diagnostic importance for clinicians in various fields of medicine encountering COVID-19 patients and its complications.

Meningoencephalitis associated with COVID-19: a systematic review.

With the growing number of COVID-19 cases in recent times. significant set of patients with extra pulmonary symptoms has been reported worldwide. Here we venture out to summarize the clinical profile, investigations, and radiological findings among patients with SARS-CoV-2-associated meningoencephalitis in the form of a systemic review. This review was carried out based on the existing PRISMA (Preferred Report for Systematic Review and Meta analyses) consensus statement. The data for this review was collected from four databases: Pubmed/Medline, NIH Litcovid, Embase, and Cochrane library and Preprint servers up till 30 June 2020. Search strategy comprised of a range of keywords from relevant medical subject headings which includes "SARS-COV-2," "COVID-19," and "meningoencephalitis." All peer reviewed, case-control, case report, pre print articles satisfying our inclusion criteria were involved in the study. Quantitative data was expressed in mean ± SD, while the qualitative date in percentages. Paired t test was used for analysing the data based on differences between mean and respective values with a p < 0.05 considered to be statistically significant. A total of 61 cases were included from 25 studies after screening from databases and preprint servers, out of which 54 of them had completed investigation profile and were included in the final analysis. Clinical, laboratory findings, neuroimaging abnormalities, and EEG findings were analyzed in detail. This present review summarizes the available evidences related to the occurrence of meningoencephalitis in COVID-19.

A 16-Year-Old Boy With Cough and Fever in the Era of COVID-19.

A 16-year-old white boy with a history of chronic lung disease of prematurity, cough-variant asthma, and incidental lung nodules presented to the emergency center in spring 2020 with acute onset dry cough, shortness of breath, and fever. An initial history, gathered from his mother because of the patient's respiratory distress, revealed no recent travel. However, his mother is a health care worker at a hospital, and sick contacts included ongoing contact with a friend with cold-like symptoms. He had a variety of animals at home, including a dog, cats, fish, rodents, and reptiles. He had a history of vaping tobacco products >6 months ago. Fever and respiratory symptoms were associated with fatigue, chest tightness, abdominal pain, and myalgias. On examination, he was ill appearing and had tachycardia, tachypnea, borderline hypoxia with an oxygen saturation of 91% on room air, diminished breath sounds at the lung bases, and unremarkable abdominal examination results. A chest radiograph was consistent with the lung examination, revealing bilateral lower lobe hazy infiltrates. He showed initial improvement for 48 hours with antibiotics, intravenous fluid resuscitation, oxygen via nasal cannula, albuterol, and prednisone. Subsequently, he worsened with persistent high fever, increasing respiratory distress with pulmonary findings, and severe persistent epigastric pain, which added a layer of diagnostic complexity. As this patient's clinical course evolved and further history became available, pulmonary medicine and infectious diseases services were consulted to guide diagnostic evaluation and treatment of this patient early in the era of coronavirus disease 2019.

COVID-19 in cancer patients can be challenging to screen in a resource limited setting.

During this COVID-19 pandemic, patients with symptoms such as fever, cough, sore throat, and coryza were advised to have RT-PCR testing for SARS-CoV-2 infection. We described here an elderly female with chronic lymphocytic leukemia, who presented with atypical symptoms that were not directly attributable to COVID-19. This patient was admitted to the non-COVID-19 ward for supportive care. Later, her chest x-ray revealed pneumonia that was confirmed to be COVID-19 by RT-PCR testing several days later. In resource-poor settings where molecular testing results suffered from delays or were altogether unavailable, the use of diagnostic imaging such as a chest x-ray could serve as a quick guide in the assessment and management of these patients especially if the imaging results suggest COVID-19 infection.

Neurogenic Cough Associated with Hyperintensity in Dorsal Medulla: Case Report and Anatomical Discussion.

BACKGROUND: The nucleus tractus solitarius and paratrigeminal nucleus, which are implicated in the processing of airway-derived sensory information, are found in the dorsal medulla. The mechanism and localization of higher-order processing of urge to cough is poorly understood, and much of the existing anatomical localization is limited to animal studies. CASE DESCRIPTION: A 44-year-old Caucasian lady underwent elective foramen magnum decompression for symptomatic Chiari I malformation; postoperatively she had resolution of Chiari symptoms but developed an intractable neurogenic cough. She has no significant medical history or premorbid respiratory issues. Postoperative magnetic resonance imaging of her head demonstrated signal change in the left dorsal medulla, corresponding with the nucleus tractus solitarius and paratrigeminal nucleus. CONCLUSIONS: We suggest that this lesion explains her isolated new cough and localizes the pathway for "urge to cough" to this region of the medulla.

Functional connectome-based biomarkers predict chronic codeine-containing cough syrup dependent.

PURPOSE: Codeine-containing cough syrup (CCS) is considered among the most popular drugs of abuse in adolescents worldwide. Accurate prediction and identification of CCS dependent (CCSD) users are crucial. This study aimed to identify a brain-connectome-based predictor of CCSD using a machine learning model based on a ten-fold cross-validation logistic regression (LR) classifier. METHODS: 40 CCSD users and 40 healthy control (HC) subjects underwent functional magnetic resonance imaging to construct weight functional networks. Partial correlation analysis was used to analyze relations between abnormal network metrics and clinical characteristics (BIS total scores, CCS abuse duration, and mean CCS dose) in CCSD. A ten-fold cross-validation LR classifier was used to classify CCSD users and HC subjects. RESULTS: The CCSD group showed significantly abnormal nodes and connections in the right posterior cingulate, right middle insula, bilateral prefrontal cortex, parietal lobe, temporal lobe, occipital lobe, and cerebellum. Furthermore, higher characteristic path length and lower clustering coefficient (Cp), global efficiency, and local efficiency (Eloc) were observed in the global topologies in CCSD. The abnormal global properties (Cp and Eloc) and node properties of the prefrontal cortex were significantly correlated with clinical characteristics (BIS-11 scores, CCS abuse duration) in CCSD. The LR classifier models demonstrated accuracy, sensitivity, specificity, precision, and AUC of 82.5%, 82.5%, 82.5%, 76.8%, and 82.5%. CONCLUSIONS: These data demonstrate that abnormal functional connectome may be closely linked to clinical characteristics in CCSD. Functional connectome-based biomarkers can be a powerful tool for personalized diagnosis of CCSD in the future.

Determinants of Chiari I progression in pregnancy.

Chiari Malformation type 1 (CM-I) is congenital or an acquired anomaly of the hind brain; develops when the cerebellar tonsils recede downwards below the foramen magnum. Recurrent post tussive suboccipital headache is the common presentation in a pregnant woman and the diagnosis is usually missed or delayed due to lack of formal understanding of this neurological pathology. Much has been written regarding presentation, morphology and the treatment of CM-I; however, little is known when the etiology is acquired or an iatrogenic in its evolution. Similarly, unknown is the progression of CM-I (diagnosed or undiagnosed) in pregnancy. The objective of this study is to elucidate the causes of progression of CM-I in pregnancy, and how this can be avoided. A detailed literature review has been conducted to find the case reports or case studies on association of CM-I in pregnancy; therefore, the risk factors regarding the progression have been sought. There is a lack of literature on timing, mode of anesthesia, and the management of CM-I. Moreover, authors have sought a questionnaire to screen these patients at pre-conception, intrapartum visits if, the initial diagnosis is delayed. Crucial points of concern including but not limited to the diagnosis, pre-conception counseling, timing of intervention during pregnancy, and mode of anesthesia, have been discussed in detail. In summary, a formal management algorithm has been proposed to avoid the rapid progression of this complex neurological pathology especially, in women of child bearing age and/or during pregnancy.

Clinical characteristics of COVID-19 in children compared with adults in Shandong Province, China.

AIMS AND BACKGROUND: The COVID-19 outbreak spread in China and is a threat to the world. We reported on the epidemiological, clinical, laboratory, and radiological characteristics of children cases to help health workers better understand and provide timely diagnosis and treatment. METHODS: Retrospectively, two research centers' case series of 67 consecutive hospitalized cases including 53 adult and 14 children cases with COVID-19 between 23 Jan 2020 and 15 Feb 2020 from Jinan and Rizhao were enrolled in this study. Epidemiological, clinical, laboratory, and radiological characteristics of children and adults were analyzed and compared. RESULTS: Most cases in children were mild (21.4%) and conventional cases (78.6%), with mild clinical signs and symptoms, and all cases were of family clusters. Fever (35.7%) and dry cough (21.4%) were described as clinical manifestations in children cases. Dry cough and phlegm were not the most common symptoms in children compared with adults (p = 0.03). In the early stages of the disease, lymphocyte counts did not significantly decline but neutrophils count did in children compared with adults (p = 0.02). There was a lower level of CRP (p = 0.00) in children compared with adults. There were 8 (57.1%) asymptomatic cases and 6 (42.9%) symptomatic cases among the 14 children cases. The age of asymptomatic patients was younger than that of symptomatic patients (p = 0.03). Even among asymptomatic patients, 5 (62.5%) cases had lung injuries including 3 (60%) cases with bilateral involvement, which was not different compared with that of symptomatic cases (p = 0.58, p = 0.74). CONCLUSIONS: The clinical symptoms of children are mild, there is substantial lung injury even among children, but that there is less clinical disease, perhaps because of a less pronounced inflammatory response, and that the occurrence of this pattern appears to inversely correlate with age.