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PRACTICE: Niamh O’Carroll, John Fitzsimons, and Siobhán Carr Asthma unresponsive to simple treatment in a child BMJ 2008; 336: 447 [Full text]

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Don't forget mediastinal masses as a cause for unresponsive "asthma"

Matthew J Murray, James C. Nicholson, Consultant Paediatric Oncologist; Donna McShane, Consultant Respiratory Paediatrician   (25 February 2008)

Don't forget mediastinal masses as a cause for unresponsive "asthma" 25 February 2008
Matthew J Murray, Consultant Paediatric Haemato-Oncologist Department of Paediatrics, Box 181, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, James C. Nicholson, Consultant Paediatric Oncologist; Donna McShane, Consultant Respiratory Paediatrician Send response to journal: Re: Don't forget mediastinal masses as a cause for unresponsive "asthma"	The article by O’Carroll et al highlights some of the important issues to consider in the assessment and management of childhood asthma unresponsive to simple treatment in the primary care setting [1]. It is surprising however that the authors omit malignancy from their list of alternative differential diagnoses and would consider the prescription of oral steroids without first excluding a mediastinal mass in such a patient [2]. Rarely, childhood leukaemia or lymphoma may present with symptoms indistinguishable from asthma, with progressive airway obstruction secondary to external lymph node compression causing wheeze and shortness of breath. At worst, this could proceed to critical airway compression and ultimately respiratory arrest [2]. Commencement of simple standard asthma therapy, i.e. steps 1 or 2 of the British Thoracic Society’s (BTS) asthma guidelines [3] may result in a partial clinical response, but inevitably deterioration will ensue at which point a chest X-ray, if performed, reveals a mediastinal mass. The NICE guidelines for referral for suspected cancer clearly state that “the primary healthcare professional should be ready to review the initial diagnosis in patients in whom common symptoms do not resolve as expected” and “must be alert to the possibility of cancer when confronted by unusual symptom patterns.” [4] More specifically the guideline states that “childhood cancer is rare and may present with symptoms and signs associated with common conditions” and, in addition, “shortness of breath is a symptom that can indicate chest involvement but may be confused with conditions such as asthma.” Healthcare professionals should therefore always be alert to the possibility of malignancy presenting with respiratory symptoms. Administration of oral steroids to a child with undiagnosed leukaemia or lymphoma carries significant risks. Tumour lysis syndrome may be inadvertently precipitated and these patients may present to hospital in renal failure. Moreover, such pretreatment may make the subtype diagnosis and disease staging difficult to assess, further compromising the ability to provide these patients with the most appropriate and effective treatment. Of greatest concern is the evidence that oral steroid pretreatment in childhood malignancy is associated with adverse outcome [5]. The NICE guidelines for referral for suspected cancer state that a key priority is education of healthcare professionals to ensure that timely and appropriate investigations are ordered [4]. O’Carroll et al have missed the opportunity to convey an essential learning point in their article, namely that a chest X-ray would be advised in those children failing to respond to simple standard asthma therapy (i.e. steps 1 and 2 of the BTS guidelines) and certainly prior to commencing oral steroid treatment. Furthermore, chest X-ray should also be performed if there are uncertainties over the diagnosis, or if a change in the pattern of asthma symptoms occurs [2]. Without such an approach, a small number of children will continue to be misdiagnosed and mistreated as asthma with potentially catastrophic sequelae. References 1. Niamh O'Carroll, John Fitzsimons, Siobhán Carr. Asthma unresponsive to simple treatment in a child. BMJ 2008;336:447. (23 February.) 2. Peet A, Grundy R, Morland B, Stevens M. Differential diagnoses for asthma should include mediastinal masses. BMJ 2001;322:302 3. British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: a national clinical guideline. July 2007. http://www.brit- thoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guidelines/asthma_fullguideline2007.pdf 4. NICE referral guidelines for suspected cancer in adults and children. June 2005. http://www.nice.org.uk/guidance/index.jsp?action=byID&r=true&o=10968#documents 5. Revesz T, Kardos G, Kajtar P, Schuler D. The adverse effect of prolonged prednisolone pretreatment in children with acute lymphoblastic leukemia. Cancer 1985;55:1637-40. Competing interests: None declared