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Dyspnea in a college athlete

Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Jonathan P. Parsons, M.D.

Assistant Professor of Internal Medicine

The Ohio State University Medical Center

Columbus, Ohio

Submit your comments to the author(s).

History

An 18 year-old female college student presents to the student health center complaining of cough and chest tightness that occurs frequently with exercise. She is on the varsity field-hockey team and notes she occasionally has trouble keeping up with the other players during practice and games. Her coach has been criticizing her frequently for what he construes as “poor effort.”   Her cough is episodic and is non-productive.  Her dyspnea seems to occur after several minutes of exercise, and she states it feels like she cannot get a deep breath.  She does not notice symptoms at other times of the day when she is not exercising.  She has been particularly stressed emotionally recently as her first final exam period in college is approaching, and her field-hockey team has advanced to the semifinals of the conference tournament.  Her review of symptoms is otherwise unremarkable.

Her past medical history is only significant for a torn knee ligament two years prior to her current presentation.  She has no known history of asthma and does not have problems with perennial allergies.  She takes oral contraceptive pills and nutritional supplements and denies any known drug allergies.  She is a freshman in college and does not smoke.  She admits to alcohol use in moderation and denies any illicit drug use.  Her family medical history is unremarkable; her sister and parents are healthy without significant medical problems including asthma.

Physical Exam

On physical exam, she is a healthy, age-appropriate female in no acute distress. The head and neck exam is benign without stridor. Lung exam reveals normal breath sounds without wheezing. Heart exam reveals a regular rhythm with no murmurs, gallops, or rubs. Abdominal exam is benign. The extremities are without cyanosis, clubbing or edema. The neurologic exam is non-focal.

Lab

Spirometry:  FVC of 104% of predicted, FEV1 of 98% of predicted, normal FEV1/FVC ratio, and normal flow-volume loops.

Electrocardiogram:  Normal sinus rhythm, normal intervals, and no ST-segment changes.

Eucapnic voluntary hyperventilation testing:  13% drop in FEV1 compared to baseline documented at 10 minutes post-test.

Question 1

Given the history and objective testing provided, what is the most likely diagnosis in this case?

References

  1. Rundell, K. W., and D. M. Jenkinson. 2002. Exercise-induced bronchospasm in the elite athlete. Sports Med. 32(9):583-600.
  2. Gotshall, R. W. 2002. Exercise-induced bronchoconstriction. Drugs 62(12):1725-1739.
  3. Parsons, J. P., Kaeding, C., Phillips G., Jarjoura, D., Wadley, G., Mastronarde, J.G. 2007. Prevalence of exercise-induced bronchospasm in a cohort of varsity college athletes. Med Sci Sports Exerc.In Press.
  4. Parsons, J. P., and J. G. Mastronarde. 2005. Exercise-induced bronchoconstriction in athletes. Chest 128(6):3966-74.
  5. Shawdon, A. 1995. Gastro-oesophageal reflux and exercise. Important pathology to consider in the athletic population. Sports Med 20(2):109-16.
  6. Helenius, I., and T. Haahtela. 2000. Allergy and asthma in elite summer sport athletes. J.Allergy Clin.Immunol. 106(3):444-452.
  7. Brauer, M., and J. D. Spengler. 1994. Nitrogen dioxide exposures inside ice skating rinks. Am.J.Public Health 84(3):429-433.
  8. Hallstrand, T. S., J. R. Curtis, T. D. Koepsell, D. P. Martin, R. B. Schoene, S. D. Sullivan, G. N. Yorioka, and M. L. Aitken. 2002. Effectiveness of screening examinations to detect unrecognized exercise-induced bronchoconstriction. J.Pediatr. 141(3):343-348.
  9. Parsons, J. P., J. M. O'Brien, M. R. Lucarelli, and J. G. Mastronarde. 2006. Differences in the evaluation and management of exercise-induced bronchospasm between family physicians and pulmonologists. J Asthma 43(5):379-84.
  10. Rundell, K. W., and B. A. Spiering. 2003. Inspiratory stridor in elite athletes. Chest 123(2):468-74.
  11. Rundell, K. W., R. L. Wilber, L. Szmedra, D. M. Jenkinson, L. B. Mayers, and J. Im. 2000. Exercise-induced asthma screening of elite athletes: field versus laboratory exercise challenge. Med.Sci.Sports Exerc. 32(2):309-316
  12. Holzer, K., and J. A. Douglass. 2006. Exercise induced bronchoconstriction in elite athletes: measuring the fall. Thorax 61(2):94-6
  13. Holzer, K., S. D. Anderson, H. K. Chan, and J. Douglass. 2003. Mannitol as a challenge test to identify exercise-induced bronchoconstriction in elite athletes. Am J Respir Crit Care Med 167(4):534-7.
  14. Anderson, S. D., G. J. Argyros, H. Magnussen, and K. Holzer. 2001. Provocation by eucapnic voluntary hyperpnoea to identify exercise induced bronchoconstriction. Br J Sports Med 35(5):344-7.
  15. National Asthma Education and Prevention Program. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma Update on Selected Topics--2002. J Allergy Clin Immunol 110(5 Suppl):S141-219.
  16. McKenzie, D. C., S. L. McLuckie, and D. R. Stirling. 1994. The protective effects of continuous and interval exercise in athletes with exercise-induced asthma. Med.Sci.Sports Exerc. 26(8):951-956.
  17. Rundell, K. W., B. A. Spiering, D. A. Judelson, and M. H. Wilson. 2003. Bronchoconstriction during cross-country skiing: is there really a refractory period? Med.Sci.Sports Exerc. 35(1):18-26.
  18. Shturman-Ellstein R, Z. R., Buckley JM, Souhrada JF. 1978. The beneficial effect of nasal breathing on exercise-induced bronchoconstriction. Am Rev Respir Dis. 118(1):65-73.
  19. Schacter, E. 1982. The protective effects of a cold weather mask on EIA. Ann Allergy(46):12-16.
  20. Miller, M. G., J. M. Weiler, R. Baker, J. Collins, and G. D'Alonzo. 2005. National athletic trainers' association position statement: management of asthma in athletes. J Athl Train 40(3):224-45.