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Cyanosis, Cough, and Breathing Difficulty in a Six year Old One midnight, a six year old asthmatic boy was rushed to an ER because of cyanotic spell (blue lips and face). A frightened mother reported that her son woke up suddenly, coughing with difficulty of breathing. She found him sitting straight up with his face blue. He is screaming and clutching his chest with pain. He become limp and not responsive for a couple of minutes. The mother did no see any unusual movement of the arms and legs. He did no loss consciousness nor did not loss control of the bowel and urine. He was not sleepy after this event. Upon arrival at the ER, he was comfortable and no longer having any cyanosis, pain, or respiratory difficulty. All of his vital signs were normal. His growth was at 50%. His oxygen saturation was 98%. The physical examination was completely normal. The mother reported that he had two other similar events of cyanosis but not as dramatic as this last one. Both cyanotic episodes happened at night while he was at his bedroom. Mom described it as chest pain, shortness of breath, with bluish lips and fingers nails. She gave him nebulized albuterol and he got better. Mom reported also that her son had one fainting spell about one month before while he was running at the gym. No one noticed any sign of seizures. He denied feeling that his heart is skipping or racing. He also denied having difficulty of breathing while playing. The family history is strong for asthma. There was no family history of sudden death or heart problems in the family. Discussion: Most primary care physcians will think of heart problem like dysrhythmia (supraventricular tachycardia or prolonged QT syndrome). Other heart problems like cardiomyopathy, anomalous coronary artery, atrial myxoma, or aortic stenosis. They will consult a pediatric cardiologist. Other possibilities are pulmonary (lung) problems like vascular ring or mediastinal mass that might causing intermittent symptoms. Chronic aspiration and pulmonary hypertensiona can explain also the cyanosis. A remote possibility is seizure disorder. Cyanotic spells could be a sign of siezures. Since most of the respiratory episodes occured at night and he is asthmatic, gastroesophagel reflux was strongly considered. Eshophagogastrodoudenoscopy (EGD) was done and it was positive for gastroesophageal reflux. He was treated with medications for acid reflux and the child was sent home. Leo Leonidas, MD, FAAP
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