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Failed Methacholine Challenge Test

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I'll appoligize ahead of time if this gets too lengthy. I took my 8 1/2 year old for a methacholine challenge test today (at my request) because I have been disputing his diagnosis of asthma for over a year now. A brief hx of my child:

-Healthy until appx 3 years old after starting daycare

-choronic strep tonsillitis until 4 years of age when he had a tonsillectomy and adnoidectomy.

-did well for appx 6 months and started having one sinus infection after another until the age of 6

-went back to ENT and to an allergy specialist in Knoxville and had allergy testing that was positive for mostly fall weeds, dust mites and cockaroach

-Has been doing two allergy shots a week since 6 and has been pretty healthy since

So here is the kicker. When he was 6 he was also given a baseline PFT and one after some medicine in a neb. I was never given those results and assumed that it was fine and the allergies were discussed. He was already on nasonex and singulair from the ped for the sinus infections/possible allergies. He goes every 6 months after this for check ups. At his 7 year appt a new person sees us and is rewiewing his medical hx with us and mentions he was diagnosed a year before with asthma. This child has never wheezed, had a chronic cough or complained. He plays and runs and keeps up with all the other kids just fine. They never treated it otherwise just kept him on the nasonex and singulair. This year 8 year old appt. I asked if we could prove once and for all if he has it or not so they did the test. He had to be off all his meds for 8 weeks before this test. I have not noticed any difference in him since stopping the meds. The only out of the ordinary thing we noticed with him was when he was running laps for soccer this spring (coach ran them hard too and the other boys were whining also) is that he would start out really good and then about half way thru he was holding the upper side of his chest and said he was having a little trouble catching his breath. He would walk it off and keep going. So he does his test today and by the 5th dose he has a reaction. They said that after each dose his PFT was declining and by the end it dropped significantly to indicate asthma. The did say he had a quick recovery. I grilled them pretty hard to prove to me that this was accurate. I asked how a otherwise healthy child with no apparent symptoms could have asthma. Like I said before he does not wheeze, have a chronic cough or complain. I did mention the soccer thing and they said that that was probably how he reacts and otherwise does not exhibit many symptoms since he his healthy, exercises and we manage the allergies well. The respiratory therapist did say when he had the last dose of the medicine he did have some mild wheezing and diminished lung sounds and recovered quickly after xopenex. Now we were sent home with rescue inhaler to use if he gets like that after hard exercise and to use asthmanex during soccer season to see if there is any difference. I really thought the outcome was going to be different and I'm having a hard time accepting this. The irony for me is that he is the child I did not expect this for. My now 4 year old had so many allergy type reactions from the time he was 3 months old, reflux, was a wheeze bag and did all of the breathing treatments starting at 14 months until 3 years. He is now off all meds, doing fine and does not have any allergies or asthma that we know of. Go figure. Thanks for listening.

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you say he isn't showing any symptoms, and then describe a symptom - holding his chest and having some difficulty breathing during strenuous exercise. wheezing is *not* a necessary symptom for having asthma. a chronic cough isn't either. if he's exercising a lot and otherwise eating great and staying healthy, then his tendency towards lung inflammation and constriction (asthma) will be mostly self-contained by the body. that's a good thing - it's mild, and he may well not need daily medication at all. it's a good thing to know about in case issues arise in the future, but until then... it doesn't really change anything.

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Not all cases of asthma have ongoing symptoms of cough or wheezing. Those who are triggered by allergy or exercise will not show these signs until exposed to the triggers. It is entirely possible for allergy meds to keep an allergy at bay, including asthma symptoms, especially if they're taken on a regular basis.

My own asthma is allergy induced. I will wheeze, needing my inhaler, at the beginning of the colder months when our forced-air furnace starts up (thus spreading dust into the air). I also start to wheeze when exposed to the air inside a house with cats for a length of time. I expect my daughter (7 yo) will be developing asthma in her teen years too, due to her pattern of allergy: eczema reactions, changing to food reactions, then (eventually) breathing reactions...she already gets nose bleeds from certain tree pollens.

Michelle

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you say he isn't showing any symptoms, and then describe a symptom - holding his chest and having some difficulty breathing during strenuous exercise. wheezing is *not* a necessary symptom for having asthma. a chronic cough isn't either. if he's exercising a lot and otherwise eating great and staying healthy, then his tendency towards lung inflammation and constriction (asthma) will be mostly self-contained by the body. that's a good thing - it's mild, and he may well not need daily medication at all. it's a good thing to know about in case issues arise in the future, but until then... it doesn't really change anything.

I am glad to know about it and we will deal with/treat it accordingly. The specialist is very good and I trust him. They did wonders for my youngest. I have been less than informed over the first two years and it finaly came to pass that I called them out on everything and told them that I felt there were things that needed addressed with me that were not. Not any more! Despite that, he has and is being treated properly. I have really never delt with any asthma that is not "text book" so I was not as informed. Thanks for the reply it helps understand somethings better from someone who knows.

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Not all cases of asthma have ongoing symptoms of cough or wheezing. Those who are triggered by allergy or exercise will not show these signs until exposed to the triggers. It is entirely possible for allergy meds to keep an allergy at bay, including asthma symptoms, especially if they're taken on a regular basis.

My own asthma is allergy induced. I will wheeze, needing my inhaler, at the beginning of the colder months when our forced-air furnace starts up (thus spreading dust into the air). I also start to wheeze when exposed to the air inside a house with cats for a length of time. I expect my daughter (7 yo) will be developing asthma in her teen years too, due to her pattern of allergy: eczema reactions, changing to food reactions, then (eventually) breathing reactions...she already gets nose bleeds from certain tree pollens.

Michelle

I do think that it stems from his allergies. They also felt since he has been on the singulair for about three years (with the exception to do the test) that it helped keep things alright. At least he only has to do the one medication during soccer and if necessary we now have the inhaler.

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Is he gluten free? The reason I ask is because asthma is often related to inflammation. In my case my asthma disappeared totally within a short time gluten free. I took Singulair for years and also had to use a daily inhalor. I have had no need for either since I was finally diagnosed.

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Someone I know from another forum had her asthma, and allergies, clear up on giving up dairy products. Anyway, I think look at possible food intolerances for it is a good idea.

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No he isn't gluten free. The ped and allergist don't think there is a problem since his ttg was 2 and at this point he is not having gi problems. He did have a history of constipation as a baby up until around 3 1/2 years old where we went thru a lot of mineral oil, apple juice, fleets enemas, gastrografin enema x-rays, and miralax. The only thing that seems to trigger it now is too much dairy. I asked for the anti gliadin antibodies and no one would order it for me saying there are too many false positives from other things. I did try him on it for a week and that is all we lasted with it. He did not seem to mind. My husband did not think it was necessary and pretty much convinced me that he did not need it either. So maybe I need to look at it again. I would like him to get the other tests done and I would like to have his iron stores and vitamin D checked. He is fair skined like me but I think he still looks pastey. He is 8.5 and yesterday he was 50# and 48 1/2". Weight wise he is gaining and he grew a little, but I am concerned since he grows slow that the inhaled steroids could possiblly slow him down more. I don't know much about that. Maybe he needs his vitamin D checked for that too. I also saw an article, I don't know how credible it is, about a link with low vit D and asthma. To me a child his age who eats balanced and gets ample sunshine ( I have been having the boys get out in the sun without sunscreen and they have got a cute little tan :P ) shouldn't be deficient. So I would like it checked too. The only one I think will entertain this is the nurse practitioner at the peds office. She is very open. He already had his yearly check up so I don't know how to approach this. Now I am being honest so be gentle, I don't believe I would have stuck to a gluten free diet without the positive tests so I think that is part of the reason I gave up on it with my son.

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No he isn't gluten free. The ped and allergist don't think there is a problem since his ttg was 2 and at this point he is not having gi problems. He did have a history of constipation as a baby up until around 3 1/2 years old where we went thru a lot of mineral oil, apple juice, fleets enemas, gastrografin enema x-rays, and miralax. The only thing that seems to trigger it now is too much dairy. I asked for the anti gliadin antibodies and no one would order it for me saying there are too many false positives from other things. I did try him on it for a week and that is all we lasted with it. He did not seem to mind. My husband did not think it was necessary and pretty much convinced me that he did not need it either. So maybe I need to look at it again. I would like him to get the other tests done and I would like to have his iron stores and vitamin D checked. He is fair skined like me but I think he still looks pastey. He is 8.5 and yesterday he was 50# and 48 1/2". Weight wise he is gaining and he grew a little, but I am concerned since he grows slow that the inhaled steroids could possiblly slow him down more. I don't know much about that. Maybe he needs his vitamin D checked for that too. I also saw an article, I don't know how credible it is, about a link with low vit D and asthma. To me a child his age who eats balanced and gets ample sunshine ( I have been having the boys get out in the sun without sunscreen and they have got a cute little tan :P ) shouldn't be deficient. So I would like it checked too. The only one I think will entertain this is the nurse practitioner at the peds office. She is very open. He already had his yearly check up so I don't know how to approach this. Now I am being honest so be gentle, I don't believe I would have stuck to a gluten free diet without the positive tests so I think that is part of the reason I gave up on it with my son.

I would put him on the diet for a few months. The reason why I say this is because of the high rate of false negatives on the panels even for adults. A false positive panel is really rare but in children the rate of false negatives is even higher than for adults. Celiac disease can present in many more ways than just gut issues and for some those gut issues can take years to appear. It can negatively impact both growth and brain function. I would give anything to have had my son diagnosed before his growth plates had fused. It is really hard for a young man to be abnormally short and can have a lot of negative impact on their self image and social life. If your son is willing to do the diet for a while you may get the answer when you go in for your next check up and find his position on the growth charts has improved as well as his asthma. One clue we had with my son was that he dropped from the 65th percentile at birth to the -10. That should have clued doctors in that something was wrong but unfortunatly it didn't.

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fyi - the inhaled steroids do not have the same frequency or depth of long term consequences (like stunted growth) that systemic corticosteroids do, because they are mostly acting only in the lungs.

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I agree with Ravenwood Glass. I posted this earlier, but I think it warrants an additional post:

http://brain.oxfordjournals.org/cgi/content/full/124/5/1013

http://pn.bmj.com/cgi/content/abstract/8/2/77

http://jnnp.bmj.com/cgi/content/abstract/79/3/315

http://www.jimmunol.org/cgi/content/abstract/178/10/6590

http://archneur.ama-assn.org/cgi/content/abstract/63/10/1440

http://jnnp.bmj.com/cgi/content/abstract/76/7/1011

http://pediatrics.aappublications.org/cgi/...ract/113/6/1672

http://pediatrics.aappublications.org/cgi/...full/114/6/1734

http://cvi.asm.org/cgi/content/abstract/11/3/515

http://jnnp.bmj.com/cgi/content/abstract/74/4/490

http://brain.oxfordjournals.org/cgi/content/full/126/3/685

http://pmj.bmj.com/cgi/content/abstract/78/921/393

http://www.neurology.org/cgi/content/abstract/58/8/1221

These are just journal articles that cite the manifestation of neurological symptoms regarding Celiac. Some are ONLY neurological manifestations. That is the type of Celiac I have (cerebellar, occulomotor & word retrieval).

Additionally, her comment about inflammation, in general, is quite appropriate. It isn't a far stretch that systemic inflammation can be caused by the gut.

My one child's asthma presented with the typical "hack"-type of coughing daily. When his asthma was very severe, I would notice the rib dysfunction and "belly breathing" that is typical. My daughter, on the other hand, presented with severe fatigue. What we found was that her breathing while sleeping was so diminished that her oxygen saturation levels were decreasing to the point that it would signal her body to wake up in order to take a deep breath! This occurred so frequently! Oddly, though, it was not diagnosed as "apnea" because it was truly an asthmatic problem.

I hope this helps some. I hope you have success with getting to the bottom of this. It's frustrating when it happens to you -- it's frustrating and scary when it's your child.

(((hugs)))

Lynne

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Well I have an update. Jack went for his check up with the allergist. He has gained weight (I can tell he is getting a little butt :lol: ) he is now 60 lb and 51 inches!(he will be 9 in Feb.) He has been complaining of growing pains. He had his pft and he did really well. They were shocked because he did way better than what they had predicted for him. I got really excited to hear this because I took him off the singulair (at the recommendation of specialist and ped). I did do the asmanex during this last season of soccer and we noticed no significant difference in his performance. So the only thing he is getting is zyrtec, nasonex and his allergy shots! The specialist said then keep him off the singulair that sometimes less is better. I do think his symptoms are triggered by strenous exercise, however it is mild. My dad had the same problem while running in the army. He had asthma as a child.

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I'll appoligize ahead of time if this gets too lengthy. I took my 8 1/2 year old for a methacholine challenge test today (at my request) because I have been disputing his diagnosis of asthma for over a year now. A brief hx of my child:

-Healthy until appx 3 years old after starting daycare

-choronic strep tonsillitis until 4 years of age when he had a tonsillectomy and adnoidectomy.

-did well for appx 6 months and started having one sinus infection after another until the age of 6

-went back to ENT and to an allergy specialist in Knoxville and had allergy testing that was positive for mostly fall weeds, dust mites and cockaroach

-Has been doing two allergy shots a week since 6 and has been pretty healthy since

So here is the kicker. When he was 6 he was also given a baseline PFT and one after some medicine in a neb. I was never given those results and assumed that it was fine and the allergies were discussed. He was already on nasonex and singulair from the ped for the sinus infections/possible allergies. He goes every 6 months after this for check ups. At his 7 year appt a new person sees us and is rewiewing his medical hx with us and mentions he was diagnosed a year before with asthma. This child has never wheezed, had a chronic cough or complained. He plays and runs and keeps up with all the other kids just fine. They never treated it otherwise just kept him on the nasonex and singulair. This year 8 year old appt. I asked if we could prove once and for all if he has it or not so they did the test. He had to be off all his meds for 8 weeks before this test. I have not noticed any difference in him since stopping the meds. The only out of the ordinary thing we noticed with him was when he was running laps for soccer this spring (coach ran them hard too and the other boys were whining also) is that he would start out really good and then about half way thru he was holding the upper side of his chest and said he was having a little trouble catching his breath. He would walk it off and keep going. So he does his test today and by the 5th dose he has a reaction. They said that after each dose his PFT was declining and by the end it dropped significantly to indicate asthma. The did say he had a quick recovery. I grilled them pretty hard to prove to me that this was accurate. I asked how a otherwise healthy child with no apparent symptoms could have asthma. Like I said before he does not wheeze, have a chronic cough or complain. I did mention the soccer thing and they said that that was probably how he reacts and otherwise does not exhibit many symptoms since he his healthy, exercises and we manage the allergies well. The respiratory therapist did say when he had the last dose of the medicine he did have some mild wheezing and diminished lung sounds and recovered quickly after xopenex. Now we were sent home with rescue inhaler to use if he gets like that after hard exercise and to use asthmanex during soccer season to see if there is any difference. I really thought the outcome was going to be different and I'm having a hard time accepting this. The irony for me is that he is the child I did not expect this for. My now 4 year old had so many allergy type reactions from the time he was 3 months old, reflux, was a wheeze bag and did all of the breathing treatments starting at 14 months until 3 years. He is now off all meds, doing fine and does not have any allergies or asthma that we know of. Go figure. Thanks for listening.

Let me start by saying, "I am not a doctor." That being said I have done Methacholine Challenge Tests. I have practiced respiratory therapy for over 20 years. From the information you gave. And I understand it is not comprehensive. IMHO it sounds like your son may have exercise induced asthma. Not a huge deal. Your son made it to the fifth level of the Methacholine. That is pretty good. Most people have a reaction after that much irritation. Exercise induced asthma is helped by two things. 1.) the inhaler before strenuous exercise and 2.) strenuous exercise.

Keep your eye on him for signs and symptoms of asthma. Treat the exercise induced asthma before it affects him, keep him clear of irritants, such as smog, cigarette smoke and harsh chemicals, and will probably do well. As he exercises symptom free his lungs should get stronger and possibly out grow this reaction.

Good Luck. Hope my input can give you some peace of mind.

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Let me start by saying, "I am not a doctor." That being said I have done Methacholine Challenge Tests. I have practiced respiratory therapy for over 20 years. From the information you gave. And I understand it is not comprehensive. IMHO it sounds like your son may have exercise induced asthma. Not a huge deal. Your son made it to the fifth level of the Methacholine. That is pretty good. Most people have a reaction after that much irritation. Exercise induced asthma is helped by two things. 1.) the inhaler before strenuous exercise and 2.) strenuous exercise.

Keep your eye on him for signs and symptoms of asthma. Treat the exercise induced asthma before it affects him, keep him clear of irritants, such as smog, cigarette smoke and harsh chemicals, and will probably do well. As he exercises symptom free his lungs should get stronger and possibly out grow this reaction.

Good Luck. Hope my input can give you some peace of mind.

I am curious how he will do when he plays soccer again and when we start riding our bikes alot (it is too cold now). I try to encourage as much physical activity as possible. Now that I am feeling so much better I expect we will be doing a lot more things together. I plan on signing him up for swimming classes next month. He has been doing that since he was 3. Now that it is winter I want him to have an activity to keep him active. I just hate that he has been medically labled. He can do pretty much anything he wants, but for some future occupations the "asthma" will disqualify him. Oh well, he will adjust and will find his niche. I'm just excited that he is doing so well and suprising the doctors! Maybe mama does know a little something. :lol:

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