A clinical case of intricate tracheal disease and asthma

Context: Asthma is the most common inflammatory disease of the airways in children. The term problematic asthma is used to describe children with chronic symptoms or acute severe exacerbations, or both, not responding to standard asthma therapy. Case Presentation: We describe the case of a 5 years old girl with a history of recurrent respiratory infections and asthma since the first months of life, with a poor response to conventional therapies (antibiotics, high dose corticosteroids combined with long-acting β2 agonists and oral leukotriene-receptor antagonists). In some cases she needed hospitalization for the important respiratory engagement and radiological findings of pulmonary consolidations, predominantly localized to the right lung. Computed tomography angiography (CTA), described a mild tracheobronchomalacia caused by the right innominate artery compression and a dense tissue mediastinal extrinsic compression of the main bronchus of the middle lobe, defined a Middle Lobe Syndrome (MLS). Evidence Acquisition: MLS is defined as a recurrent or chronic collapse or infection of the middle lobe of the right lung. There is often a history of multiple treatments with antibiotics and anti-asthmatic drugs for ‘‘recurrent pneumonia’’ or ‘‘asthma’’, as in our patient. Chest X-ray is the first-line diagnostic tool, especially on the lateral view. CT-scan and bronchoscopy are considered useful for diagnosis or treatment. Treatment depends on etiology of MLS. Conclusion: In case of severe asthma symptoms co-morbidities must be evaluated. MLS is frequently unrecognized in children and thinking of it is a prerequisite for diagnosis, especially when recurrent respiratory infections or asthma symptoms are predominantly localized to the right lung.