Recurrent pneumonia in children — structured oral (viva)

Branch 1 — Definition and first move

Examiner: "This girl has had four pneumonias. What is your definition of recurrent pneumonia, and what is the first thing you want to establish?" Candidate: Recurrent pneumonia is two or more episodes in a year, or three or more ever, each radiographically confirmed and with the film clearing between episodes. My first move is to review all the previous films and decide whether the pneumonias struck the same site each time or different sites, because that single question splits the differential into structural, same-site causes and systemic, different-site causes. Here the episodes involved both lower lobes, so this is a different-site, systemic pattern. [1]

Branch 2 — Pattern and differential

Examiner: "It is a different-site pattern. What does that tell you, and what is your differential?" Candidate: A different-site pattern points to a systemic failure of airway defence rather than a fixed lesion. My differential is recurrent aspiration, immunodeficiency, cystic fibrosis, and primary ciliary dyskinesia, with congenital heart disease and severe asthma also considered. In this girl the chronic nasal discharge, recurrent otitis media, and unexplained neonatal respiratory distress point strongly toward primary ciliary dyskinesia. [1] [2]

Examiner: "Why does the neonatal history matter?" Candidate: Unexplained neonatal respiratory distress in a term infant is a recognised early feature of primary ciliary dyskinesia, and combined with chronic rhinosinusitis and recurrent otitis media it forms a classic clinical cluster. I would also ask specifically about situs inversus, which occurs in around half of these children. [2]

Branch 3 — Investigation

Examiner: "How will you investigate her?" Candidate: Because this is a systemic, different-site pattern, I would pursue a host work-up rather than image a single lobe. I would screen immune function with a full blood count, immunoglobulins, and vaccine-response titres, exclude cystic fibrosis with a sweat test and genetics given the faltering growth, and pursue primary ciliary dyskinesia with nasal nitric oxide and specialist ciliary studies given the clinical cluster. A high-resolution CT would define any established bronchiectasis. [2] [3]

Branch 4 — Why early diagnosis matters

Examiner: "Why does it matter that you pin down the cause now?" Candidate: Because the common endpoint of untreated recurrent infection is chronic suppurative lung disease and bronchiectasis, which is irreversible. Diagnosing primary ciliary dyskinesia or another systemic cause early lets me start airway clearance, treat infections adequately, and place her in specialist multidisciplinary care before permanent airway damage develops. In Aboriginal and Torres Strait Islander and other high-burden communities the imperative to act early is even greater. [3] [2]