Visual Diagnosis: A 17-month-old Girl With Persistent Cough

Presentation

A 17-month-old girl with a past medical history of birth at 31 weeks’ gestation and several episodes of bronchodilator-responsive wheezing is transferred for management of a pneumothorax. One month ago, she was diagnosed with influenza A based on a dry cough. The patient refused to take oseltamivir and her cough persisted. Over the past 2 to 3 days, the cough has worsened in frequency and developed a “wet” quality. Recently, several of the coughing episodes were associated with nonbloody, nonbilious posttussive emesis. While waiting to be seen by her primary pediatrician today, she developed back swelling, which prompted more immediate evaluation.

Other than recent symptoms of rhinorrhea, the remainder of her review of systems is negative. Throughout this illness, she has continued normal voiding and stool patterns as well as normal levels of activity.

As noted previously, the girl was born at 31 weeks’ gestation via cesarean delivery due to eclampsia. She did not require endotracheal intubation but received supplemental oxygen for 2 weeks. Her immunizations are up to date. She is small for her age and has reached developmental milestones. Currently, she is prescribed beclomethasone dipropionate twice daily and albuterol as needed for previous wheezing and coughing episodes. She has never been hospitalized. Family history includes asthma in her father.

On physical examination, her rectal temperature is 100.8°F (38.2°C), heart rate is 123 beats per minute, respiratory rate is 18 breaths per minute, blood pressure is 96/78 mm Hg, and oxygen saturation is 99% on 4 L/min of supplemental oxygen via nasal cannula. Her weight is 8 kg (3rd percentile). She appears well-nourished, is in no apparent distress, …