"If Mom would just let me play video games again, I would feel better.”
CHALLENGING CASE: Obese 10-Year-Old with "Foggy Brain," Trouble in School, and Nasal Congestion: What’s the Diagnosis?
A 10-year old boy presents to the clinic with difficulty sleeping, headaches, problems concentrating (which he describes as feeling “foggy brained”), and nasal congestion. The symptoms started in late September. Since then, his grades have dropped. He is normally an A student, but his mother says recently he has been receiving Bs on tests, and even some Cs.
Because he is overweight, his mother recently enrolled him in youth soccer in order to encourage him to cut down on video game playing and lose weight. He has been going to soccer practice outside since the symptoms started. When asked what makes his symptoms better or worse, he replies, “If Mom would just let me play video games again, I would feel better.” He currently takes no medications. Family history is notable for asthma in his father.
On examination, he is 56 inches tall, weighs 102 pounds, and has a BMI of 23. His blood pressure, heart rate, and respiratory rate are within normal limits. Physical exam is notable for nasal congestion, scant clear discharge from both nostrils, dark circles and puffiness under the eyes, watery eye discharge, and pale pink discoloration of the nasal mucosa. No foreign bodies in the nose or nasal polyps are noted. Ears and throat are clear. Tonsils are not enlarged or inflamed. No persistent adenoids are noted. No lymphadenopathy is noted.
Lungs are clear, without wheezing, rales, or rhonchi. Heart is regular sinus rhythm. No murmurs are appreciated. Neurological exam is unremarkable.
The boy slouches and yawns several times during the exam. Intermittently, he fidgets, sniffles, and scratches his eyes and nose nervously. He appears embarrassed to be at the doctor’s office. You ask him if his eyes and nose are itchy, and he mumbles “sometimes.” You ask him about depressive symptoms, bullying, and other problems at school, all of which he denies. He repeats, “I wish I could just play video games again.”
Lab tests, including CBC, BMP, and urinalysis, are all within normal limits.
What's your diagnosis?
A. Seasonal allergic rhinoconjunctivitis
B. Sleep apnea
The correct answer is A. Seasonal allergic rhinoconjunctivitis
According to guidelines from the American Academy of Family Physicians,1 diagnosis of allergic rhinitis and empiric treatment can be started on the basis of history and physical exam, without a role for radiographic imaging or confirmation with IgE-specific testing.
In this case, diagnosis was based on the clinical history and exam findings: abrupt onset of this patients’ symptoms, which occurred after he started playing soccer outside during allergy season, as well as telltale signs of allergy such as the “allergic shiners,” itchy nose and eyes, pale nasal mucosa, and nasal congestion. Sinonasal timors, CSF rhinorrhea, and chronic rhinosinusitis are important to rule out, but bilateral rhinorrhea makes these conditions less likely.
Fluticasone propionate (Flonase), an intranasal corticosteroid, is prescribed as first line because the patient’s symptoms are affecting his quality of life. While some intranasal corticosteroids have been associated with decreased growth in children and adolescents, research suggests that Flonase does not affect growth.1
First-generation and some second-generation antihistamines should be avoided. They may worsen his cognitive symptoms and have a further negative impact on his school performance.
A recent review of studies on children aged 10 to 19 years and published over the last 15 years found that allergic rhinitis and allergic rhinoconjunctivitis can have a significant impact on quality of life in adolescents.2 Nasal congestion often occurs more frequently at night and can interfere with sleep. Sleep disruption in turn can interfere with daytime functioning and negatively impact school performance, attendance, and academic achievement. Allergic rhinitis and allergic rhinconjunctivitis have also been linked to cognitive problems, irritability, inattention, mood disorders (especially anxiety and depression), and emotional disruption. Teens and preteens, however, may be embarrassed about their symptoms and not talk about them.
The patient was advised to avoid/reduce exposure to allergens, such as immediately removing clothing and taking a shower after soccer practice or using an air filtration system with humidifier at home. A neti-pot to rinse out nasal allergens was indicated. An indoor sport such as swimming was encouraged.
Patient education materials about healthy eating and exercise were provided in order to encourage weight loss.
Follow-up should include evaluation for asthma (given the family history of asthma and the comorbidity between the two conditions), and evaluation to rule out OSA, given the patient’s obesity. He should also be assessed for weight loss, and for the need for professional weight loss management.
If the boy fails to respond to empiric treatment, IgE skin or blood testing to test for the specific allergens should be considered.
1. AAFP. Allergic rhinitis clinical practice guidelines. July 2015. Accessed Sept 4 2018 at: https://www.aafp.org/patient-care/clinical-recommendations/all/allergic-rhinitis.html.
2. Blaiss MS, Hammerby E, Robinson S, et al. The burden of allergic rhinitis and allergic rhinoconjunctivitis on adolescents: A literature review. Ann Allergy Asthma Immunol. 2018;121:43-52.e3.