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Case based discussion
A toddler with a cough and wheeze refractory to treatment
  1. Shivanthan Shanthikumar1,2,3,
  2. Tommy Lwin1,
  3. Chung W Chow2,4,
  4. Joe Crameri5,
  5. Jo Harrison1,2,3
  1. 1Respiratory Medicine, Royal Children's Hospital, Melbourne, Australia
  2. 2Department of Paediatrics, The University of Melbourne, Victoria, Australia
  3. 3Murdoch Children's Research Institute, Victoria, Australia
  4. 4Anatomical Pathology, Royal Children's Hospital, Melbourne, Australia
  5. 5Paediatric Surgery, Royal Children's Hospital, Melbourne, Australia
  1. Correspondence to Dr Shivanthan Shanthikumar, Respiratory Medicine, Royal Children's Hospital, 50 Flemington Road, Parkville, Melbourne, VIC 3052, Australia; shivanthan.shanthikumar{at}rch.org.au

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Tommy Lwin (Medical Student)

A 20-month-old girl weighing 12 kg presented with 2 weeks of worsening dry cough and wheeze. Aside from respiratory symptoms she was otherwise well, without fever or weight loss. There was no history of foreign body inhalation or choking. She had no significant personal or family medical history, and her immunisations were up to date. Prior to admission she had been treated for 1 week for a community-acquired pneumonia with oral amoxicillin and roxithromycin, as well as for a first presentation asthma exacerbation with oral prednisolone (2 mg/kg) and inhaled salbutamol, three hourly. Despite these interventions no clinical improvement had been noted. On examination, her respiratory rate and oxygen saturations were normal. She had mild respiratory distress, a loud biphasic wheeze and a prolonged expiratory phase. A chest X-ray (CXR) demonstrated hyperinflation of the right lung (figure 1A). Given the suspicion of a foreign body obstructing a right-sided airway, a rigid bronchoscopy was performed which showed an isolated submucosal lesion in the right main bronchus causing airway narrowing (figure 1B). To further characterise the lesion, a CT of the chest was performed, which demonstrated a subcarinal mass (figure 1C), causing significant extrinsic compression of the distal right main bronchus and bronchus intermedius. There was no intraluminal perforation of the mass.

Figure 1

(A) Chest X-ray at presentation showing hyperinflation of right lung. (B) Image from rigid bronchoscopy showing occlusion of right main bronchus by submucosal lesion. (C) Initial CT scan showing subcarinal mass compressing the right main bronchus. (D) Lymph node biopsy demonstrating necrosis with nuclear debris surrounded by a thin layer of caseation and epithelioid cells with occasional Langhans giant cells. (E) Repeat CT scan showing reduction in size of mass with ongoing right main bronchus compression.

Shivanthan Shanthikumar (Respiratory Fellow) and Jo Harrison (Respiratory Consultant)

The most likely differential diagnoses for a subcarinal mass in this patient include a neoplastic …

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