Asthma or not asthma? That is the question

A 12-year-old boy with a family history of atopy and no relevant personal medical history was referred to the Pediatric Allergy Out-Clinic due to a persistent cough lasting 1 year, refractory to multiple therapeutic interventions. He presented with a daily productive cough, occasionally leading to vomiting, associated with exertional dyspnea during moderate physical activity. He denied any clear seasonality or identifiable triggers. He reported episodes of low-grade fever 2-3 days per month, dysphagia, and occasionally experienced a subjective sensation of food impaction. Blood tests performed at another center showed sensitization to house dust mites (Dermatophagoides), olive pollen, pellitory (Parietaria), and animal dander. Physical examination was unremarkable. Spirometry performed in the Pediatric Allergy outpatient clinic revealed an obstructive ventilatory pattern with a negative bronchodilator response. High-resolution chest CT scan revealed multiple bilateral cylindrical bronchiectasis, predominantly in the upper lobes, as well as diffuse dilation of the thoracic esophagus up to 6 cm in diameter, extending to the esophagogastric junction, suggestive of stenosis at this level. The patient was urgently referred to the Pediatric Pulmonology and Pediatric Gastroenterology department. Further gastrointestinal studies-including an esophagogastroduodenal transit study, upper digestive endoscopy, and esophageal high-resolution manometry-confirmed a diagnosis of type II achalasia. Surgical intervention (Heller myotomy technique and Dor anterior fundoplication) was performed, and 30 months post-surgery, the patient remains asymptomatic, pulmonary function has normalized, and chest CT scan revealed no pleuroparenchymal abnormalities. Achalasia should be considered in the differential diagnosis of chronic productive cough unresponsive to treatment in children.