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Difficult-to-control asthma in 13-year-old boy

Case Editor - Judd Flesch

Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Stephen Kirkby, MD


The Ohio State University and Nationwide Children's Hospital

Columbus, OH

Richard Shell, MD

Associate Professor of Pediatrics

The Ohio State University and Nationwide Children's Hospital

Columbus, OH

Submit your comments to the author(s).


A 13-year-old Caucasian boy with a long-standing history of poorly controlled asthma was referred for evaluation in the pediatric pulmonary clinic.  He had daily symptoms of cough, wheezing, and shortness of breath. Exercise, seasonal allergies and viral illnesses were known triggers of these symptoms.  Nighttime cough and wheezing were infrequent.  Over the past year, the boy had several exacerbations requiring oral steroids and had missed a great deal of school, though he had never required hospital admission.

Over the past few months, he had averaged at least two daily doses of albuterol for rescue relief of asthma symptoms.  Low-dose inhaled corticosteroids combined with a long-acting beta agonist had been prescribed by his primary care physician as a controller medication.  His family reported inconsistent compliance with this therapy. His only other medication was over-the-counter antihistamine, which was used only during times of “bad allergies.”  Asthma had initially been diagnosed at the age of two.  His past medical history was otherwise significant for chronic constipation. Growth had always been normal.  There was no indication of abnormally frequent respiratory tract or ear infections. There was no reported snoring.

Our patient lived on a farm with his parents in rural Ohio.  Straw and hay seemed to make his asthma symptoms worse. He denied increase in symptoms when working with the farm animals or when around the family dog.  His father smoked cigarettes, but indicated that he did not smoke around the child. The dog was an indoor pet. There were no cats or birds.  Family history was positive for asthma and seasonal allergies.

Physical Exam

Physical exam revealed a well-nourished and healthy-appearing boy with normal vital signs, oxygen saturation and growth parameters. His nasal mucosa was boggy with clear discharge. His oropharynx showed normal tonsil size. There were mild bilateral expiratory wheezes on lung auscultation. There was no clubbing or eczema. The remainder of the exam was negative.


Pulmonary function testing was performed: 

FEV1/FVC: 68%

FEV1: 52% of predicted (1.77 L)

FVC:  62% of predicted ( 2.61 L)

There was a 17% improvement in FEV1 following bronchodilator administration.


Chest radiograph

Question 1

The condition LEAST likely to contribute to the severity of asthma symptoms in this patient is:


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