Background: Bronchoalveolar lavage (BAL) is often utilized to evaluate lower airway inflammation in children with complex pulmonary conditions. The implications of eosinophilia in BAL are understudied, and thus, its finding is often underutilized diagnostically. In particular, the role of BAL in pediatric eosinophilic esophagitis (EoE) has not been thoroughly explored. Objective: To assess the presence of bronchoalveolar lavage (BAL) eosinophilia and respiratory symptoms in pediatric patients with eosinophilic esophagitis (EoE). Study and Methods: A retrospective chart review included patients aged ≤18 years who underwent simultaneous esophagogastroduodenoscopy (EGD) and flexible bronchoscopy with BAL at a tertiary pediatric hospital between 2013 and 2023. Patients with biopsy-confirmed EoE were compared to those requiring these procedures for other conditions (grouped as the control arm of the study). BAL eosinophilia was defined as >1% of the total cell count. Demographic, clinical, and laboratory data were extracted and analyzed. Results: A total of 132 patients were reviewed, and 103 (45 with EoE and 58 controls) were analyzed. Control group diagnoses included bronchopulmonary dysplasia (N=24, 41%), cystic fibrosis (N=23, 40%), and primary ciliary dyskinesia (N=11,19%). BAL eosinophilia was significantly more common in the EoE group (36% vs. 10%, P=.002). Among EoE patients, chronic cough was as prevalent as gastroesophageal reflux symptoms. The presence of other atopic conditions or infection did not correlate significantly with BAL eosinophilia. Conclusion: BAL eosinophilia is significantly more prevalent in pediatric patients with EoE compared to those with other pulmonary conditions. These findings support the inclusion of EoE in the differential diagnosis of chronic cough and BAL eosinophilia in pediatric patients. Prospective studies are needed to validate these findings and refine diagnostic approaches.

Title: A pediatric patient with PCD and broncholith formation.Swetha Gannarapu, MDUniversity of Texas Southwestern Medical Center, Department of Pediatrics, Division of Pulmonology and Sleep Medicine, Dallas TexasSwetha.gannarapu@utsouthwestern.eduMuhanned Abu-Hijleh, MDUniversity of Texas, Southwestern Medical Center, Department of Medicine, Division of Pulmonary and Critical Care MedicineMuhanned.abu-hijleh@utsouthwestern.eduFolashade Afolabi, MDUniversity of Texas Southwestern Medical Center, Department of Pediatrics, Division of Pulmonology and Sleep Medicine, Dallas, TexasFolashade.afolabi@utsouthwestern.eduAndrew S. Gelfand, MDUniversity of Texas Southwestern Medical Center, Department of Pediatrics, Division of Pulmonology and Sleep Medicine, Dallas, TexasAndrew.gelfand@utsouthwestern.eduYadira M. Rivera-Sanchez, MD (corresponding author)University of Texas Southwestern Medical Center, Department of Pediatrics, Division of Pulmonology and Sleep Medicine, Dallas, TexasYadira.rivera-sanchez@utsouthwestern.eduTo the editor:We present a 17-year-old male of Hispanic descent with a diagnosis of PCD who manifested with symptoms of recurrent fever and bronchiectasis exacerbations, signs and symptoms of increased cough, sputum production with sputum discoloration, and fatigue with an associated decrease in baseline lung function. PCD diagnosis had been made at the age of 11 with nasal nitric oxide (nNO) levels of 9 nL/min and transmission electron microscopy (TEM) of nasal cilia, revealing the partial absence of the outer dynein arms (ODA). PCD genetic panel was inconclusive, revealing three homozygous variants of unknown significance (VUS) in DNAH5, CCDC65, and DNAH8 (Table 1). Relevant past medical history included a left lower lobe (LLL) lobectomy at the age of 12 for recurrent bronchiectasis exacerbations requiring hospitalization due to failure to respond to oral antibiotics and ventilation-perfusion (V/Q) scan findings of almost absent perfusion to the LLL.The patient’s lung function remained normal but showed a decrease from baseline in the forced expiratory volume in 1 second (FEV1). Flexible bronchoscopy showed an endobronchial polypoid lesion with surrounding friable mucosa at the level of the LLL lobectomy stump. BAL cultures were positive for Aspergillus niger and Pseudomonas aeruginosa (Pa). The patient had a known colonization with Pa.For findings of Aspergillus niger in association with recurrent fevers, respiratory symptoms, and failure to respond to antibacterials, Voriconazole was started and continued for 4 months. It was discontinued after 4 months due to side effects, including photosensitivity. Inhaled Tobramycin, alternated with inhaled Aztreonam, were continued as per the baseline plan of care. Repeat flexible bronchoscopy again showed the same endobronchial polypoid lesion at the level of the LLL lobectomy stump with friable surrounding mucosa. Since our institution does not have a pediatric interventional bronchoscopy service, the patient was referred to the adult interventional pulmonary program for flexible bronchoscopy with biopsy consideration. Differential considerations at that time included an Aspergilloma, a broncholith, and a foreign body. Therapeutic aspiration was performed to remove thick mucoid secretions, primarily in the left tracheobronchial tree, with relatively long remaining left lower lobe airways, including the superior segment airway and basilar segments airways with distal stump. The polypoid lesion had a white, rough surface and was wedged at the level of the superior segment airway.  The polypoid abnormality was extracted as a single entity using a large jaw flexible forceps without significant resistance or bleeding (Figure 1). The entire lesion measured 7 mm x 5 mm. The clinical and pathology findings were consistent with a broncholith.Post-operative clinic visits have shown improvement in respiratory symptoms.

Objective: To determine if pediatric patients who have laterality defects and meet the diagnostic criteria for Primary Ciliary Dyskinesia (PCD) evaluation are being referred to and evaluated by pediatric pulmonologists. Subjects and methods: A retrospective chart review using the electronic medical record was conducted at Dallas Children’s Health for patients with laterality defects who met two or more of the PCD evaluation criteria: laterality defect, chronic daily cough, and chronic daily nasal congestion starting in infancy, and neonatal respiratory distress of unclear etiology requiring oxygen or positive pressure for 24 hours or longer. The referral rates to pediatric pulmonary, genetics, and whether patients were evaluated for PCD were determined. Results: The electronic medical record search for laterality defects identified 433 patients. Of these, 14 patients were excluded because they were found not to have a laterality defect, and 38 because they did not have enough data (birth history, onset, and or characteristics of cough) for analysis. Neonatal respiratory distress was excluded as a symptom for those patients with a known etiology for their respiratory distress. Of the 381 patients who met the criteria for analysis, 192 (50%) met only one criteria for PCD evaluation (laterality defect), and 50% met 2 or more of the criteria. Of the 84 patients who met the minimum 2 criteria for PCD evaluation, 45% were referred to pulmonary, 14% to genetics, and only 15% were evaluated for PCD. Of the 27 patients who met all 4 PCD criteria for evaluation, 96% were referred to pulmonary, 85% to genetics, and 85% were evaluated for PCD. Among the 381 patients studied, there were no significant differences in the referral rate by the patient’s demographics, including sex, race, ethnicity, and insurance type. The sensitivity of referrals increased with the number of PCD criteria. Conclusions: A substantial number of pediatric patients meeting the criteria for PCD evaluation with 2 PCD referral criteria are not referred to pediatric pulmonologists, and a larger number are not being evaluated for PCD. As expected, patients with 3 or 4 PCD referral criteria have a higher rate of referral to pulmonary than those meeting the required 2 criteria. Nonetheless, a substantial number of patients who meet all 4 criteria for evaluation are not being evaluated for PCD even when referred to pulmonary or genetics. This highlights the importance of PCD education and awareness efforts for Pediatric specialists and subspecialists, including pediatric pulmonologists.