Dr. Amdekar discusses 8 cases of patients presenting with breathlessness as a major symptom and subsequent diagnosis made with key observations made during history taking.

To read other originals by Dr. YK Amdekar, click here.

---

Take the quiz to test your knowledge

---

Clinical application of basic concepts

Breathlessness is a symptom but much before it ensues, there are subtle clues for physicians to observe. Mild increase in respiratory rate is obvious especially in older children, only if carefully looked for. Mothers of young children often notice fast abdominal movements. Thus, tachypnoea is the earliest sign and it is at this stage, one can find out a probable cause.

Increase in heart rate is not evident to a patient unless an older child complains of palpitation. If this early phase is missed, respiratory distress manifests with chest retractions – evidence of increased work of breathing. By now, effects of hypoxia and/or hypercarbia are seen and the earliest symptom of such abnormality is change in behavior– state of confusion, drowsiness or irritability. If this is missed, cyanosis develops as a late sign indicating respiratory failure.

---

Case-based discussions

Case 1

A 2-year-old healthy child presents with fever for a day followed by dry cough, noisy breathing and breathlessness that worsened over the next 12 hours, and fever continued. Dry cough suggests involvement of upper airways and noisy breathing denotes obstruction to passage of air that must have resulted in breathlessness. Fever indicates infection and as other symptoms have followed quickly after the onset of fever, it is most likely to be viral infection.

Physical examination revealed not sick-looking but uncomfortable child with stridor, RR 40/min, HR 115/min, mild fever, marked suprasternal retraction, normal breath-sounds, no foreign sounds, and other systems were normal. The child would look very sick in case of bacterial infection. These findings are in favour of acute laryngeal obstruction due to viral infection – viral laryngitis - croup.

Generally, such a disease is short-lasting and there is no need for any tests. However, in case of doubt, CBC and X-ray of neck in lateral position may be helpful. Treatment is symptomatic with oxygen and hydration. Prognosis is good and recovery is expected in a day or two.

---

Case 2

A 2-year-old healthy child presents with mild fever and cold followed a day later by breathlessness for which the child required hospitalisation. This history is almost similar to croup but this child has not reported any cough or noisy breathing. Absence of cough and noisy breathing rules out affection of larger airways but smaller airways such as bronchioles do present without cough. It also may be a cardiac disease such as acute viral myocarditis. Further physical examination would differentiate between these two possibilities.

Physical examination revealed no sickness but discomfort, rapid shallow breathing, RR 60/min, HR 120/min. Chest showed bilateral emphysema with diminished breath sounds without foreign sounds, liver 3F+, liver span 7 cm, not tender, hepato-jugular reflex absent, spleen just palpable, no cardiomegaly or murmur. These findings favour diagnosis of acute bronchiolitis.

Generally with such a classical presentation, there is no need of any tests. Chest X-ray would have shown bilateral emphysema which is evident on clinical examination itself. Treatment is symptomatic with oxygenation and hydration. Prognosis is good and recovery is expected within a few days.

---

Case 3

A 4-year-old child presented with history of fever and cough for two days followed by breathlessness that worsened over the next 12 hours. The child was apparently well prior to this illness. The fever was high with sick interfebrile period. Cough was mild. High fever with sick interfebrile period suggests bacterial infection and mild cough points to probable lung affection. Breathlessness starting two days after onset of fever denotes progression of infection likely to be developing pneumonia.

Physical examination showed sick-looking child, RR 40/min HR 105/min, intercostal chest retraction, chest movements reduced on right lower part anteriorly, TVF/VR increased, impaired note on percussion, and bronchial breath sounds with few crepitations. Other systems were normal. These signs are typical of pneumonia of right middle lobe.

Investigations – Hb 11 Gm%, WBC 18000 P 78 L 22 E 0 Pl N. Chest X-ray revealed haziness on the right side suggesting diagnosis of acute bacterial pneumonia. The child was treated with Amoxy-clav and recovered well.

---

Case 4

An 8-year-old healthy child presented with high fever for a day followed by breathlessness that increased over the next few hours requiring urgent hospitalisation. Breathlessness in this child has come up within a day of onset of fever and increased in severity quickly. It suggests immune response and not just the extention of infection that would have taken a longer time to manifest more so in an older child. So this suggests development of severe pleural effusion. As there has been no history of any preceding infection, it is likely to be occult infection like tuberculosis to which this child has reacted immunologically.

Physical examination showed a highly febrile child, uncomfortable, RR 45/min HR 120/min, chest movements absent on the left side, trachea and apex beat shifted to the right, dull note on percussion up to second intercostal space, absent breath sounds, no foreign sounds. These findings are classical of large pleural effusion. Aetiology is a guess – most likely tuberculosis.

Investigations – Hb 12 Gm%WBC 18000 P 80 L 15 E 2 M 3 Pl N. Chest X-ray marked haziness all over the left side with mediastinal shift to right, pleural fluid WBC 5000 P 75 Proteins 2.6 Gm suggestive of acute inflammation. It is worth to note that neutrophilic leukocytosis in the blood and pleural fluid denotes acute inflammation – either infective or non-infective origin. Progress of symptoms in a short time suggests non-infective immune inflammation.

Attempts to prove tuberculosis in this child failed as culture and GeneExpert were negative in gastric aspirate and pleural fluid. This is not unusual because focus of tuberculosis in this child is expected to be very small situated in the subpleural region with large immune reaction in the form of pleural effusion. There was no history of contact either. Thus, diagnosis in this child is based on local epidemiology and ruling out other infections. So final diagnosis was pleural effusion due to tuberculosis.

---

Case 5

A 6-year-old child presented with acute onset of cough and breathlessness over the last 12 hours. Cough was severe and dry. There was no fever. The child had a similar episode a few months ago and was treated with some medicines – details not known. There was family history of asthma via the father. This history clearly suggests bronchial asthma. Even in absence of past and family history, one would have considered the same diagnosis because acute onset of severe cough suggests airway disease and absence of fever denotes non-infective cause.

Physical examination showed an uncomfortable child, but not sick, RR 35/min HR 105/min, subcostal chest retraction, audible wheeze, chest movements were bilaterally symmetrical, rhonchi + on auscultation. Other systems were normal. Diagnosis is clear – bronchial asthma.

There is no need for any tests in this child. Eosiniphilia is not diagnostic of asthma. Chest X-ray may reveal prominent bronchovascular markings and at times pathy haziness due to small areas of atelectasis due to bronchial obstruction. Serum IgE is also non-specific and does not add value to diagnosis. Pulmonary function tests are not reliable at this age as the child may not be able to perform the test optimally. Allergy tests are reserved only in resistant cases as a majority of the patients are allergic to house dust mites, pollens etc. which contribute to most allergic reactions and not commonly to food items. Other irritants such as smoke, perfumes and at times stress worsen the disease. Acute attack is best treated with nebulised salbutamol and steroids. Adrenaline is used only in case of inadequate response. Maintenance therapy may be required in a child with persistent asthma.

---

Case 6

An 8-year-old child presented with history of breathlessness over the last 2 weeks, gradually increasing and on and off cough. She was apparently well two weeks ago when she felt out of breath while coming back from school. However on rest, she felt better. Gradually, she found it difficult to move about for which she sought medical attention. There was no significant past or family history.

Progressive breathlessness with cough may be due to respiratory or cardiac disease. Significant cough indicates airway affection and considering breathlessness along with it, could it be asthma? But asthma is typically episodic and not gradually worsening. Intestitial lung disease may present with breathlessness gradually increasing, though such increase is over long time and cough is not a feature. Lung parenchymal disease often is infective and so presents with fever. So this child may be suffering from cardiac disease. In absence of significant past history, congenital heart defect can be ruled out. So it is likely to be acquired heart disease. The most common cause of acquired heart disease in children is due to complications of rheumatic fever. Though there is no past history suggestive of rheumatic fever in terms of arthritis, such an episode may be incomplete and not even diagnosed as rheumatic fever. Other acquired heart diseases are acute or chronic. Gradually worsening breathlessness suggests increased pulmonary venous congestion as in case of mitral valve affection – either stenosis or regurgitation or both.

Physical examination revealed uncomfortable child, RR 34/min HR 120/min BP 100/50 mmHg, peripheral pulses well felt, precordial pulsations, apex beat in 6th intercostal space just outside mid-clavicular line, hyperdynamic, cardiomegaly+, pansystolic murmur best heard at apex and conducted to axilla, P2 loud, liver 2F+, firm, mild tenderness, hepatojugular reflex +ve, spleen not palpable, chest occasional crepiitations. Other systems were normal. Chest X-ray and ECG also corroborated with diagnosis of Rheumatic mitral regurgitation. There was no evidence of active carditis. The child was treated with oxygen and anti-failure line of therapy followed by long term penicillin prophylaxis.

---

Case 7

A 2-year-old child presented with history of cough and breathlessness off and on and occasional episodes of fever since last one year. There was a history of not gaining weight. Absence of fever each time rules out primary infective disorder. As cough and breathlessness in this child suggests progressive disease as evident by faltering in weight, hence asthma is ruled out. Chronic interstitial lung disease would not present with significant cough and hence not likely. So respiratory causes are ruled out and so it must be a cardiac problem. Recurrent cough and breathlessness suggests pulmonary congestion and so probably left to right shunt defect such as VSD – it being the common defect.

Physical examination revealed weight- 8 kg, length 82 cm RR 40/min HR 120/min BP 90/50 mmHg, no cyanosis, peripheral pulses well felt, precordial pulsations, apex in 5th intercostal space outside midclavicular line, hyperdynamic, systolic murmur best heard in parasternal area on right side 3rd intercostal space, P2 loud, liver 3F+, firm, mild tenderness +, spleen not palpable, chest few creps+, other systems normal. These findings are in favour of ventricular septal defect with congestive cardiac failure – VSD with CCF.

Investigations include echocardiogram that confirmed moderate size VSD with pulmonary hypertension. Chest X-ray and ECG add value to final diagnosis as lung markings and other chest defects and rhythm disturbances are not detected on echocardiogram. Child was treated with anti-failure line of therapy and would need surgical correction at optimal time.

---

Case 8

A 4-year-old child presented with breathlessness over the last 12 hours that worsened over time and the child became drowsy. He was suffering from asthma and was on regular compliant treatment and well controlled. On the face of it, it may appear to be an attack of asthma but there was no cough at all, besides, the fact that he was well controlled. This should raise suspicion about the diagnosis.

Physical examination showed RR 45/min, deep and rapid breathing, chest clear no foreign sounds, HR 110/min, drowsy child responding to being called. Other systems were normal. Deep and rapid breathing with clear chest denotes metabolic acidosis and one common cause that is often hidden to begin with is diabetic ketoacidosis. On direct questioning, this child did have polyuria, polydipsia and polyphagia for last one week prior to onset of this illness. Investigations confirmed the diagnosis of diabetes mellitus. Child was treated accordingly.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.