The authors report the case of a previously fit and well six-year-old girl who presented to paediatric outpatients with a four month history of wheezing associated with intermittent cough. During her first clinic appointment, she was given a trial of salbutamol via a spacer, which appeared to reduce the wheeze and few crepitations which had been heard prior to administration of the drug. She was diagnosed with asthma and prescribed Beclomethasone and Salbutamol at this time.
This apparent initial response to salbutamol was later disputed as spirometry showed no reversibility. Also, she did not report any interval symptoms or increased wheezing with exercise or upper respiratory tract infections. Her mother did not feel that the inhalers had made any difference to her symptoms so her medications were stopped.
She developed a number of chest infections and was investigated for possible underlying conditions including cystic fibrosis and structural defects, none of which were found to be present. IgE and RAST for specific allergens were negative and a chest X-ray was completely normal. Full blood count and immunoglobulins were also normal. She was found to have low Hib and tetanus antibodies but these returned to normal after she was re-vaccinated.
The doctors treating her began to suspect tracheobronchomalacia was responsible for her symptoms and at this point, the wheeze was noted to be musical in character. At this point, she was referred for a bronchoscopy and a small piece of plastic tubing was found in her airway. It was removed successfully and she has been completely well since, with no further episodes of wheeze or cough. In retrospect she could not remember a choking episode or inhaling a foreign body.
This case demonstrates that all that wheezes is not asthma. It is important to re-evaluate and re-consider differential diagnoses when the clinical picture does not completely fit. Airway foreign bodies should be considered even with a long history of cough and no signs of respiratory distress and absence of a history of inhalation of a foreign body does not rule it out, even in older children.