Index of Suspicion

Case 1 Presentation

A 12-year-old girl is referred to you because of a “wet, mucousy cough for years.” She never wheezes and has used salbutamol intermittently without relief. She was treated as a newborn for pneumonia and has had recurrent sinusitis and middle ear effusions; ventilating tubes have been inserted twice. She never has had allergic symptoms, and there are no smokers or pets at home. Her brother has a history of recurrent upper respiratory tract infections, otitis media, sinusitis, and mild asthma.

Physical examination reveals a thin, prepubertal girl who is not acutely ill. Her growth has consistently followed the 25th percentile for height and 10th percentile for weight. She is afebrile and has a respiratory rate of 20 breaths/min. Bilateral middle ear effusions are noted. No wheezes are audible, but crackles are heard in the right middle lobe (RML). Her cardiovascular findings are normal, with the apical beat on the left side. Her liver and spleen are not enlarged. There is no digital clubbing.

Chest radiography reveals normal lung volumes, no calcifications, and alveolar opacification in the RML consistent with pneumonia. Pulmonary function test results, sweat chloride level, findings on immunologic evaluation, immunoglobulin E levels, and eosinophil count all are normal. A tuberculin skin test is negative.

Two courses of antibiotics fail to bring improvement. Computed tomography (CT) of the chest reveals bronchiectasis in the RML with volume loss as well as mild central bronchiectasis of the lower lobes. A nasal biopsy reveals the diagnosis.

Case 2 Presentation

A 2½-year-old girl is brought to the emergency department because of intermittent vomiting for 1 month. She has been eating well but has lost 1.5 kg in 2 weeks. The parents also report more wet diapers than usual.

On examination, the girl is well-developed, well-nourished, and in no distress. Her temperature is 99°F (37.2°C), heart rate …