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There are many illnesses that could mimic asthma. In this case of a nine year old girl who had asthma symptoms since 18 months old, the following were considered in the decision making:

1. Poorly controlled asthma

2. Allergic bronchopulmonary aspergillosis

3. Tuberculosis

4. Foreign body aspiration

5. Cystic fibrosis

6. Tracheal tumor

7. Functional immune globulin abnormality

8. Subglottic airway granuloma

9. Histoplasmosis or occidiomycosis

10. Rheumatologic diseases with recurrent pulmonary manifestations.

11. HIV

The following tests were done:

1. Total hemolytic complement (CH50), IgG, IgA, IgM and IgG subtype and the results were normal. This was done to rule out number 7 (Functional immune globulin abnormality). It is a blood test.

2. T-cell and B-cell counts were normal. Done to check the immune function.

3. HIV testing was considered but the parents refused because the child did not have blood transfusion and child is not sexually active.

4. Tuberculin test done (PPD) and was negative. Done to rule out tuberculosis.

5. A pH probe for for gastroesophageal reflux was mildly positive.

6. Sweat test and genetic analysis for cystic fibrosis were negative.

7. Bronchoscopy was considered but the parents refused.

8. Spiral CT scan of the trachea in 1-mm segments revealed the diagnosis.

                 The nine year old girl had Tracheal Web.

The Tracheal Web was removed by endoscopic laser treatment. Biopsy showed respiratory cells with evidence of chronic inflammation. The child’s asthma and respiratory difficulty got better. Her flow volume loop (lung function test to prove asthma) became normal.

There were only three reports of tracheal webs in the medical literature. It is believed to be congenital and was formed during the fetal life.

Some children with narrowing or stenosis of the larynx or trachea will not show any symptoms till they are school age.

Reference: PEDIATRIC NEWS, August 2003, page 47

From PubMed:   Acta Paediatr. 2002;91(4):399-402.  

Central airways stenosis in school-aged children: differential diagnosis from asthma.

Linna O, Hyrynkangas K, Lanning P, Nieminen P.

Department of Paediatrics, Oulu University Hospital, Finland.

This study assessed the value of spirometry and chest X-rays in the diagnosis of airways stenosis in the tracheal or laryngeal regions at school age. A series of 14 patients was studied. Six of them had vascular ring anomalies, four subglottic stenosis, two aberrant innominate artery, one tracheal stenosis and one a laryngeal web. Four patients were suffering from chronic cough and ten from dyspnoea, noisy breathing and cough upon physical exercise. Two had had their symptoms since infancy and five since 3-6 y of age, whereas seven had had their first symptoms at school age. Nine patients had previously been suspected of having asthma, and five of them had been using inhaled corticosteroids, one inhaled sodium cromoglycate and one peroral terbutaline without any effect. The ratio of forced expiratory volume in 1 s (FEV1) to peak expiratory flow (PEF) was abnormally high in most of the patients. All six children with vascular ring anomalies also had an abnormal aortic configuration on a chest X-ray, and narrowing of the trachea was seen in two of the four with subglottic stenosis. Two children had both chest X-rays and spirometry values within the normal limits. Conclusion: The results show that children with stenosis in the laryngeal or tracheal region may not have their first symptoms until school age. Many patients are falsely suspected of having asthma. Simple spirometry and chest X-rays will help the physician to make the correct diagnosis in these patients.
 

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Leo Leonidas, MD, FAAP, Assistant Clinical Professor in Pediatrics, Tufts University School of Medicine, Boston; Attending Pediatrician, Eastern Maine Medical Center, Bangor, Maine.

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