Chronic Cough - the Magic of a Correct Diagnosis

A 21 year old female office worker came in yesterday morning complaining of cough for the last six weeks. She had been to see a doctor who gave her a week's prescription of an antibiotic which she said she took once daily (1000mg) but she did not know the name when asked. She was also given a cough syrup and a decongestant which she also religiously took but her coughs persisted.

She was getting desperate as she coughed so much at work in an air conditioned office.  And she admitted that her coughs were worse at night and had disturbed her sleep and made her irritable. She looked miserable and she was also extremely worried about getting PTB.

As per our clinic protocol  for coughs lasting more than three weeks, I did a screening for PTB (pulmonary tuberculosis) consisting of a chest xray, sputum for AFB (acid fast bacilli) for three morning consecutively. I also took her blood for  FBC ( full blood count) and an ESR (erythrocytes sedimentation rate), a non-specific indicator of increased inflammatory activity in her body.

But most important I asked about her medical and family history. Yes, the father had PTB a long time ago but has been treated. Yes, her younger brother suffered from asthma but has more or less recovered over the years . No, she has never had asthma but she offered the information that when she coughed so bad she could hear a gritty sound in her chest. And currently she is all congested and her nose is all blocked.

I examined her chest and found it to be clear of any abnormal sounds. Her chest Xray was also normal apart from a mild congestion on her right lower lobe. Her FBC showed an allergic picture with an elevated neutrophils and ESR was mildly elevated as expected in an inflammatory condition but not too high as seen in chronic conditions such as PTB or connective tissue diseases like SLE (systemic lupus erythematosis)

There are other causes of chronic cough such as post-nasal drip and GERD (gastroesophageal reflux disease) but the history pointed to more of a recent irritant causing increased secretions and bronchospasm giving rise to incessant coughing. I surmised that her problem started with an upper respiratory tract infection likely to be viral and this was not properly managed as she was later put on (likely) a broad spectrum antibiotic and long term anti-tussive and anti-congestant that somehow  served to irritate her bronchiolar linings causing bronchospsm, increased secretions and narrowing of her airways. The narrowed airways prevented normal clearance of the accumulating secretions.

What she needed was a bronchodilator to reduce the spasm and clear her airways. That was what I gave her. Before she left my clinic yesterday I asked her to return the next morning and show me the antibiotic which was prescribed to her for my information as I wouldn't want to give the same one in case she needed it.

Early this morning she turned up with a piece of paper on which she wrote the name of the antibiotic which she got via phone from the private clinic. Unfortunately it was some garbled word which didn't look at all like any antibiotic that I knew of despite looking up in the internet! Anyway that information was no longer important to me.

What is important to me is the smiling and happy woman I see today. She says she no longer has any cough. She slept well last night after taking two oral doses of the medication I gave her. She couldn't even cough out any sputum this morning for the AFB test as her chest and throat have miraculously cleared overnight. She said her friends also commented that she no longer coughed irritably.

When she got up from the chair to leave she bent forward, extended both her hands and cupped my right hand tightly to thank me and said that she'd never been so relieved in weeks.

I am very pleased with  her fast response to the medication  and this is the kind of cases which gives me a deep  professional satisfaction.