Challenges of Silent Severe Asthma and NERD in Children

Abstract

Background: Non‐steroidal anti‐inflammatory drugs (NSAIDs) exacerbated respiratory disease (NERD) is a rare condition in the European population, especially in children. The objective of this case presentation is to high light the importance of a multidisciplinary approach to the diagnosis and treatment of asthma if concomitant diagnoses exist and NERD could be suspected. Methods: Retrospective analysis of the patient's medical data. Case presentation: An11‐year‐old girl was transferred to the pediatric intensive care unit (ICU) from the ENT surgery room for suspected anaphylaxis and severe asthma exacerbation. She had surgery because of chronic rhinosinusitis and bilateral ostiomeatal complex obstruction with nasal polyps (Figure1). The diagnosis was made 2 years before surgery, conservative medical treatment was insufficient. Sensitization to house dust mites, increased levels of total IgE, eosinophilia and asthma diagnosis was confirmed in early childhood. Nasal symptoms were predominant; therefore she was treated mainly by family and ENT doctors. Asthma symptoms were partially controlled but antiinflammatory treatment was intermittent and before surgery was not prescribed. NERD and nose polyposis inthe patient's family history was also clarified. Tachypnea, bronchial obstruction and severe desaturation occurred 20 minutes after intravenous ketoprofen given at the end of the surgery. Deterioration of vital signs led to resuscitation. Unfortunately, it was complicated byn. peroneus compression and long lasting paresis of it. Salbutamol and methylprednisolone improved asthma symptoms, but bronchospasm reoccurred in ICU after the second dose of NSAID. Therefore, NERD was suspected. Paracetamol instead of ketoprofen was prescribed, and basic asthma treatment was started. Subsequent histological examination of the polyps revealed chronic eosinophilic inflammation (Figure2). Significant eosinophilia in blood (1400/μl) and nasal smear (50%) as well as increased exhaled FeNO was found. Lung function tests showed moderate bronchial obstruction with positive reversibility test, hyperinflation and increased resistance of airways (Figure3). [...].