A 1-year-old girl presented to the local emergency department with acute wheeze and increased work of breathing. Then and during subsequent presentations, she was given varying combinations of inhaled bronchodilators, oral steroids and oral antibiotics, with no clinical benefit from any of these treatments. After several intensive care unit (ICU) admissions and failure to respond to escalating asthma preventative treatment, she was referred to our centre at age 3. Detailed history revealed an unusual but reproducible symptom complex on presentation characterised by a sore throat, gum pain, back pain and lethargy followed the next day by a dry cough with evolving dyspnea and increased work of breathing. The child subsequently presented acutely to our centre on a number of occasions. Examination during an acute episode revealed marked increased work of breathing on both inspiration and expiration, without stridor and with scattered wheeze. Within 24–48 hours, this was followed by vigorous coughing with secondary vomiting with expectoration of tenacious mucus plugs. Symptoms would only resolve once mucus plugs had been expectorated; antibiotics, steroids and bronchodilators had no …
