A 68 y/o spry grandmother presents with a ‘nagging cough’. She states she has had the cough for 3 weeks. She saw her primary doctor who prescribed antibiotics, but it made no difference. She has coughing spells that are worse at night, and she coughs so hard her chest is sore. When she has a coughing spell, she does feel short of breath. No fevers, vomiting (although she sometimes gags with her coughing spells). The chest pain is pleuritic, increased with coughing, and not associated with diaphoresis. She also notes her abdomen is a little sore from coughing. No change in bowels or urination. Her great-granddaughter who is only 2 months old is coming for Thanksgiving, and she doesn’t want to make her sick, so she came to the ED for a stronger antibiotic.
SH: No smoking.
PE: Thin elderly female, sitting upright and comfortably on the cot.
VS: BP=148/90, HR=98, RR=20, Sat=95%
Heart: RRR, No Murmurs
Lungs: Expiratory Wheeze at both bases with some rhonchi.
Abd: Soft, scaphoid. No masses. Non-tender.
Ext: Trace edema to both pre tibial areas.
1. Name at least 3 causes for this ‘Nagging Cough.’
The 3 easy things that come to mind include: Bronchospasm related cough (asthmatic bronchitis), congestive heart failure, and pertussis. A cough related to bronchospasm may need steroids and beta-agonists to break the bronchospasm and cough.
New onset CHF may present with persistent wheezing and cough. This may be worse at night because the CHF is worse supine.
Pertussis should be considered anytime a person has an acute cough illness lasting >14 days with paroxysmal cough, post tussive vomiting or inspiratory whoop (CDC case definition). (1).
Other causes may be post nasal drip (as the cough is worse at night), or medications (Captopril : an Angiotensin Converting Enzyme Inhibitor (ACEI) comes to mind with up to 2-10% of patients on this medication developing a chronic cough). (2) Additional causes include Acid Reflux (especially as the cough is worse at night), or even an endobronchial lesion can cause cough.
As she is not a smoker, it’s less likely chronic bronchitis (COPD). For a great list of causes for chronic cough, see this website from the National Lung Health Education Program:
2. Any ED medications to help with the cough?
Any time I have a patient with a remarkable persistent cough, I always consider 2 ED medications: a narcotic (which helps the pleuritic chest pain and is a great anti-tussive) and treatment for bronchospasm.
In patients without obvious wheezing but a persistent cough, I often will give a trial of albuterol / atrovent nebulizer treatment with pre/post PEFR measurements. If the patients feel better, cough less, or have substantial improvement in their PEFR, then I treat with steroids. If the patient has obvious wheezing, I always give beta agonists and steroids.
3. What cause of cough might be life threatening to the great-granddaughter?
Although pertussis is more common in young teens, this grandmother could have pertussis. Pertussis infections in the US have been increasing since the 1970’s. (3) About 60% of cases occur in kids aged 11-18 yrs (when the immunity of earlier vaccination may wane) and in adults >20. (4) In 2005, the ACIP recommended TDaP (booster vaccinations with Tetanus, Diphtheria, and Pertussis) vaccinations for children up to age 18 in order to increase immunization for pertussis.
Pertussis is very contagious with 80% secondary attack rates among susceptible persons. Additionally, there is an endemic in the US every 3-4 years (3). Initially the cough is only occasional, but then goes on to paroxysms (a succession of coughs that follow each other without inspiration). The cough can last for 2-6 weeks! And, as in this patient, the cough is worse at night. In the US, nearly all deaths from Pertussis are in infants <6months old. So if this patient does have Pertussis, she could infect her great-granddaughter, and that could become life threatening.
Interestingly, Pertussis is more common in girls than boys. (5)
About 90% of patients with Pertussis, who die, have secondary pneumonia, dehydration, hypoxia, encephalopathy, or even cerebral hemorrhage (which can occur secondary to paroxysmal coughing which elevates the ICP). (5) Blood work reveals an elevated WBC count (often 20-40K) with a profound lymphocytosis (>70%) in kids, but lymphocytosis is rare in adults. (5)
The best treatment is adequate vaccination to prevent the disease. Antibiotic treatment for Pertussis includes erythromycin or azithromycin or clarithromycin if >1 months. For infants under 1 month, azithromycin is recommended. (3)
CXR revealed congestive heart failure. EKG revealed Q waves in the inferior leads (old Inferior wall MI). Blood work was normal. As she had new onset CHF, she was started on some nitrates and lasix, and admitted to the hospital.
She was found to have an ischemic cardiomyopathy and had 2 stents placed before she was discharged in good condition, no longer with any cough as her CHF was adequately controlled.
This is not the first case I’ve seen with a persistent cough as the result of slowly developing CHF. Now I always put CHF high on my list in older patients with persistent coughs. I didn’t do a BNP, but I suspect it would have been elevated and may have helped if the CXR was not diagnostic.
1. Skoff TH, Thomas CG. Pertussis. Travelers Health-Yellow Book. Accessed at: http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/pertussis.aspx
2. Captopril Cough: EmedTV. Accessed at: http://congestive-heart-failure.emedtv.com/captopril/captopril-cough.html
3. Tiwari T, Murphy TV, Moran J. Recommended Antimicrobial Agents for the Treatment and Post exposure Prophylaxis of Pertussis, 2005 CDC Guidelines. MMRW 54(14). Accessed at: http://www.cdc.gov/mmwr/pdf/rr/rr5414.pdf
4. Pertussis—United States, 2001-2003 MMRW: 2005 Dec 54(50):1283-128, accessed at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5450a3.htm
5. Bocka JJ. Pediatrics, Pertussis. eMedicine. May 2009. Accessed at: http://emedicine.medscape.com/article/803186-overview