Частые ОРЗ у детей. Системный подход. Статья февраль 2009 (англ.)

[Наталья П.]

Summary
The child who has recurrent infections poses one of the most difficult diagnostic challenges in pediatrics. The outcome may be anything from reassurance that the child is normal to the diagnosis of a life-threatening condition. A huge range of tests is available (Box 9).




Box 9. Summary of potential investigations in the child who has recurrent infections


Suspected CF
Sweat test

CF genotype

Electrical potentials (nasal, bronchial, rectal biopsy)

Supportive tests (eg, human fecal elastase-1)

Suspected PCD

Screening: saccharine test, nasal nitric oxide

Ciliary structure and function: high-speed videomicroscopy, electron microscopy

Culture of ciliary biopsy

Genetic studies

Immunostaining of specific dynein proteins

Screening for suspected immune deficiency (referral to a pediatric immunologist mandatory for most specific immunodeficiencies)

Full blood cell count (neutropenia, lymphopenia)

T-cell subsets

Immunoglobulins

Immunoglobulin subclasses

Vaccine antibody responses

Complement studies

HIV test

Suspected gastroesophageal reflux

pH-metry

Impedance probe

Isotope milk scan

Barium swallow (exclude anatomic causes such as hiatus hernia)

Esophageal manometry

Suspected incoordinated swallowing

Videofluoroscopy

Rigid endoscopy to exclude laryngeal cleft

Suspected aspiration

HRCT scan: dependant bronchocentric consolidation (not specific)

Lipid-laden macrophages (absence probably excludes significant aspiration)

BAL pepsin (gastric contents)

Suspected structural esophageal disease

Tube esophagram

Bronchoscopy (H-type fistula)

Barium swallow

Suspected structural airway disease

Bronchoscopy

Endobronchial ultrasound

CT reconstruction

Suspected bronchiectasis

HRCT scanning

Exclude CF, PCD, immunodeficiency, tuberculosis (see other sections)

Consider excluding esophageal disease, incoordinated swallowing, reflux, and aspiration

Echocardiogram, overnight saturation studies

Suspected tuberculosis

See Box 8

Suspected cardiovascular disease

Echocardiogram (enlarged cardiac chambers caused by left-to-right shunt, vascular ring)

Barium swallow (vascular ring)

CT or MRI with vascular reconstruction (vascular ring)

Suggested vasculitis or connective tissue disease (referral to pediatric rheumatologist probably is advisable)

Erythrocyte sedimentation rate, C-reactive protein

Double-stranded DNA

Rheumatoid factor

Antineutrophil cytoplasmic antibody studies

Circulating immune complexes

Anti-glomerular basement membrane antibodies



The clinician faces a twofold challenge in determining:

1. Is this child normal? (This question may be the most difficult in all clinical practice.)

2. If this child seems to have a serious disease, how can the diagnosis be confirmed or excluded with the minimum number of the least-invasive tests?

It is hoped that, in the absence of good-quality evidence for most clinical scenarios, the experience-based approach described in this article may prove a useful guide to the clinician.