Post-infectious bronchiolitis in an infant: A case report of recurrent severe pneumonia with hypertension and global developmental delay

INTRODUCTION

Bronchiolitis obliterans (BO) is a rare chronic obstructive lung disease in children, which is characterized by progressive small-airway fibrosis following infection, transplantation, or inhalational injury^[1,2] [Figure 1]. Post-infectious BO (PIBO) is particularly associated with adenovirus in children.^[2,3] Early recognition is challenging due to nonspecific symptoms overlapping with recurrent pneumonia and asthma.^[2] We present a case of an infant with recurrent respiratory failure and adenovirus-associated BO, complicated by hypertension, severe acute malnutrition, and developmental delay.

Close

Figure 1:

Pathophysiology of bronchiolitis.

Export to PPT

CASE REPORT

A 5-month-old male infant, born to a non-consanguineous marriage, was delivered through lower segment cesarean section at term with a birth weight of 2.7 kg. The baby cried immediately after birth, and there was no history of admission to the neonatal intensive care unit; the perinatal period was uneventful. The child presented to the emergency department of a tertiary hospital with complaints of severe respiratory distress, poor feeding, and lethargy [Figure 2]. He was immediately admitted to the pediatric intensive care unit (PICU) for further management due to severe pneumonia with shock. The child was intubated and placed on a mechanical ventilator. Treatment was initiated with intravenous fluids, broad-spectrum intravenous antibiotics, nebulizations, inotropic support, and systemic corticosteroids. A detailed history revealed recurrent episodes of respiratory distress since 3.5 months of age, requiring multiple hospital admissions and prolonged PICU stays at tertiary care centers. There was no family history of similar respiratory illnesses or chronic lung disease. The patient underwent high-resolution computed tomography (HRCT) of the chest and bronchoscopy with bronchoalveolar lavage at an outside tertiary care center, which revealed the presence of adenovirus and Klebsiella pneumoniae. An immunodeficiency workup performed at the same facility showed a low CD4:CD8 ratio of 0.2.

Close

Figure 2:

Infant with post-infectious bronchiolitis obliterans on nasal prong oxygen support.

Export to PPT

Investigations

Complete blood count showed leucopenia, thrombocytosis, and moderate anemia while renal Doppler and echocardiography were normal. Fundus examination did not reveal any hypertensive or other abnormal changes. The chest X-ray showed bilateral haziness. HRCT chest revealed multiple patchy and diffuse areas of ground-glass opacities in a peri-bronchovascular distribution in bilateral lung parenchyma, which became confluent at certain points to form areas of consolidation with air bronchogram signs in the posterior segment of the right upper lobe and the postero-basal segment of the left lower lobe, suggestive of BO based on clinical and radiological correlation [Figure 3]. The child was discharged on oxygen support through nasal prongs, along with oral azithromycin and cotrimoxazole prophylaxis. The discharge medications also included syrup prednisolone, antihypertensive drugs, and metered-dose inhalers of budesonide, salbutamol, and tiotropium. In addition, the child was initiated on a nutritional rehabilitation program to address underlying malnutrition and failure to thrive. The patient was kept on regular follow-up, during which there was a history of readmission due to similar respiratory complaints. On each occasion, the child was managed conservatively, with gradual clinical improvement. Over time, the oxygen requirement decreased, and the child was successfully weaned off supplemental oxygen and maintained on room air by 1 year of age.

Close

Figure 3:

(a,b) High-resolution computed tomography chest showing bilateral peri-bronchovascular ground-glass opacities with areas of consolidation (shown by blue arrows) and air bronchogram suggestive of bronchiolitis obliterans.

Export to PPT

DISCUSSION

PIBO is a rare but severe sequela of viral pneumonia in infancy, especially following adenovirus infection.^[1,2] Management of PIBO is primarily supportive. Various therapeutic options include long-term oxygen therapy, inhaled bronchodilators, macrolides, and corticosteroids.^[3-5] Our patient developed chronic airway changes with persistent respiratory symptoms despite aggressive treatment.^[3] The coexistence of immunological dysfunction, malnutrition, hypertension, and developmental delay further complicated management.^[1]

Recent advances in managing PIBO involve exploring immunomodulatory and anti-fibrotic therapies. Studies have assessed the use of macrolides for their anti-inflammatory effects, ruxolitinib targeting the Janus kinase-signal transducer and activator of transcription pathway, and mesenchymal stem cell therapy for immune regulation and tissue repair.^[2,3] Early pulmonary rehabilitation, combined with these emerging approaches, offers hope for better outcomes in children with PIBO.^[1,4]

This case underscores the vital importance of early recognition and diagnosis of PIBO in infants showing recurrent or persistent lower respiratory symptoms, especially those with a history of severe or prolonged pneumonia and unresolved wheezing despite proper treatment.^[1,5] Prompt identification of this condition can prevent repeated respiratory failure episodes, unnecessary antibiotic use, and extended hospital stays, all of which lead to significant morbidity in affected infants.^[2] A high level of clinical suspicion, combined with supportive imaging and lung assessments, is crucial for distinguishing PIBO from other chronic lung diseases such as bronchial asthma, interstitial lung disease, and cystic fibrosis.^[3,4] Early diagnosis enables targeted treatments, including anti-inflammatory therapy, optimized bronchodilator use, infection prevention, and long-term respiratory management, which can greatly improve prognosis and reduce long-term lung complications in affected children.^[1,5]

CONCLUSION

This case emphasizes the importance of a multidisciplinary approach to management. Collaboration among pediatric pulmonologists, cardiologists, nutritionists, physiotherapists, and developmental pediatricians plays a pivotal role in optimizing clinical outcomes and enhancing quality of life. A comprehensive follow-up that includes nutritional rehabilitation, growth monitoring, developmental stimulation, and BP management is equally vital for ensuring the child’s long-term well-being and preventing complications. Early and coordinated multidisciplinary care remains the core for improving outcomes in complex pediatric conditions.