Working Diagnosis:
Exercise-Induced Bronchospasm causing near-syncope

Treatment:
Mometasone/Formoterol 100mcg/5mcg inhaler 2 puffs twice daily.
Albuterol 90 mcg inhaled
1-2 puffs every 4 hours as needed for dyspnea, or 30 minutes prior to exercise

Outcome:
After being placed on regular inhaled steroid and long-acting beta-agonist, the patient did not have any further attacks. She did not seek any additional work-up and was able to take part in all athletic endeavors without symptoms. She was gradually weaned off inhaled steroid and maintained on albuterol as needed and before workouts. The athlete is currently a Division 1 track athlete.

Author's Comments:
This case illustrates an atypical presentation of a common pulmonary disorder. In situations like this, it is absolutely essential to rule out cardiac pathology first, as was done appropriately for our patient. Unfortunately, bronchial provocation testing was not performed early on, and thousands of dollars were perhaps spent needlessly on testing for more obscure and less likely diagnoses. It is safe to assume that our patient could have returned to sport much earlier with less risk of further health decompensation, had this common pathology been considered at the onset of her symptoms.

Editor's Comments:
Mannitol testing is very helpful when initial baseline spirometry is normal but underlying asthma is suspected. Other provocative tests methods could have included exercise challenge with pre- and post-exercise spirometry, or Eucapneic Voluntary Hyperventilation (EVH) spirometry.

References:
1. Krafczyk MA, Asplund CA. Exercise-induced bronchoconstriction: diagnosis and management. Am Fam Physician 2011; 84:427–434.
2. Parsons JP, Hallstrand TS, Mastronarde JG et al. An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. Am J Respir Crit Care Med 2013; 187:1016–1027.
3. Parsons JP, Craig TJ, Stoloff SW et al. Impact of exercise-related respiratory symptoms in adults with asthma: Exercise-Induced Bronchospasm Landmark National Survey. Allergy Asthma Proc 2011; 32:431–437.
4. Parsons JP, Mastronarde JG. Exercise-induced bronchoconstriction in athletes. Chest 2005; 128:3966–3974.
5. Weiler JM, Anderson SD, Randolph C et al. Pathogenesis, prevalence, diagnosis, and management of exercise-induced bronchoconstriction: a practice parameter. Ann Allergy Asthma Immunol 2010; 105:S1–47.

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