Friday, May 11, 2012

Postinfectious Cough

I am not a huge baseball fan to begin with, and when I am, I route for the Nationals.  Thus, I pay little attention to the New York Yankees, and was not aware that Yankee player Mark Teixeira had been suffering with a cough for the past month until it the story from the New York Times came through one of my Twitter feeds. According to the story:
"Mark Teixeira had a battery of tests performed Wednesday to determine the nature of his violent and persistent cough, and he received good news. Teixeira, who has been wracked by the cough for about a month, said he was found to have nothing more serious than severe congestion in his bronchial passageways." 
Mr. Teixeira was prescribed prednisone (not something I would recommend for this) and is expected to recover soon. In addition, the doctors at New York-Presbyterian/Columbia hospital in Manhattan performed a CT scan, a lung function tests, blood tests and cultures during their work up (though I am sure the Yankees can afford this). The Times does not mention the diagnosis other than to say that the baseball player had "severe inflammation in my bronchial passageways."

I blog about this because this is one of the most common things I see in the primary care setting, it is often misunderstood and therefore misdiagnosed, it is very easily treated and there is virtually no research on this disease.

Mr. Teixeira likely has what is known as postinfectious cough. Here's the typical patient presentation:
Young healthy patient gets a typical upper respiratory tract infection (URI): cough and congestion, headache, feels ill and low grade fever. URI resolves in a matter of days, but there is a persistent cough that is getting worse, and won't go away.  Cough is usually worse at night, and the patient can't exercise because it makes them cough. On occasion the cough is so bad that the patient is winded easily and sometimes the patient thinks they may be wheezing, though they have no history of asthma.

According to the American College of Chest Physician which published evidence-based clinical practice guidelines back in 2008, the diagnosis of post infectious cough should be considered when a patient complains of cough that has been present following symptoms of an acute respiratory infection for at least 3 weeks,but not more than 8 weeks.  And while the cause of the postinfectious cough is not known, it has been thought to be due to the extensive damage of cells lining the lung and widespread airway iinflammation of the upper and/or lower airways. The good news is that this usually goes away by itself, the bad news is that it can take weeks or even months, and can be quite disruptive to patients lives; desk jockeys and baseball players alike.

To me one of the most incredible things about this illness is the lack of data on effective treatments. The ACCP review cited above did an extensive review of the literature and found very few studies that looked which treatments worked best. Given the lack of data, here is my take on the appropriate diagnosis and treatment:

Diagnosis can be made without an extensive workup when the clinical presentation is consistent with that described above and there are no other complicating factors that would indicate other possibilities. A chest X-ray may be all that is necessary to rule out any underlying severe disease and is reasonable in a patient who has been coughing for more than two weeks.

Since symptoms are caused primarily by inflammation and hyperresponsiveness/bronchoconstriction in the lungs (which is what we see in asthma), then treatment is likely best with something that treats both inflammation and bronchoconstriction in the lungs, such as an inhaled corticosteroid/long-acting beta agonist like Advair (which is commonly used in asthma).  Of note, Advair (or other ICS/LABA combinations) have not been approved by the FDA for the treatment postinfectious cough and there is no data on the use of ICS/LABA's for the treatment of postinfectious cough.  However, this is a common sense approach to the problem based on what we know about the cause, and from clinical experience I can tell you this approach works remarkably well.  Use of Advair for postinfectious cough may be the single most common off-label use of any prescription product.
There are two additional important points.  First, since inflammation can persist for weeks, it is important that Advair be used for at least 4 weeks.  If stopped too soon, before inflammation has completely resolved, symptoms may return.  This is very important, because primary care physicians who decide to use ICS/LABA inhalers for postinfectious cough may give patients a medication sample rather than a prescription.  Though the drug companies that make these products used to make samples with a month's supply of medication, most inhaler samples today have only 1-2 weeks of therapy.  Secondly, if symptoms have resolved and the patient has taken the inhaler for 4-6 weeks, the patient can safely stop the inhaler.  If symptoms return, the patient should be brought back for pulmonary function testing as this may be a new presentation of asthma.


Anonymous said...

For the last 10 days i have haf white spots on tonails.very sore throat and ears..the white spots ..sore throat and ears are ok..but now i have a really persistant and hard cough. If i wait long enough will the cough go away by itself?

Dr. Matthew Mintz said...

Can not make a specifc recommentation given the limited information you provided. However, the cough may not go away, so you should see a physician.

Susan said...

Thank you for posting this article. My doctor prescribed Advair for symptoms very similar to what you've described. I rarely use medications and your article and link were vey informative.

brandi said...

I was sick with an upper respiratory infection for 2 weeks. I was prescribed a 5 day antibiotic as well as Codeine with an antihistamine for my cough. The cough was one of the worst I've ever had, and I've had a few bouts of bronchitis before. I felt a lot better with no symptoms of cough present for about a week. Now I have a cough again with post nasal drip. Do u think this is due to the infection that I had? I take Flonase for allergies and have also been diagnosed with GERD for which I take omeprazole. Just wondering what is up with this cough given the fact that I was symptom free for a week. So annoying! -40 yr old female

Dr. Matthew Mintz said...

@brandi- sorry your cough has come back. I can't give specific medical advice over a blog since I am not able to take a full history or examine you, but if everything was better for about a week, and then came back, you should probably see a doctor. Could be post-infectious cough, but with all your other issues (allergies, GERD) there are a host of things that could be going on. Also, 40 year old females shouldn't have several bouts of bronchitis, so there may be something chronic going on. I am hopeful you don't smoke (if you do that is likely a major part of the problem).

Julie said...

I was hoping you could answer some questions and shed some light on my situation. Please! I am a 46-year-old female nonsmoker have never smoked anything,ever. I am no stranger to bronchitis and I usually get it once a year around flu season. However, the first week of June of this year I came down with a cough that came out of the blue I did not have a cold or a fever or anything I just had chest tightness and a cough that turned into a productive cough. I went on antibiotics and an inhaler and the neither one of those helped. Eventually the cough got better and it did someone go away for about 2 weeks and then it came back about a week and a half ago. I have never had asthma and I do not have a history of adult allergies. I had a chest x-ray about 6 weeks ago and it was clear and I had a spirometry test that turned out fine. But my cough still lingers. It is very odd because it is only in the morning and it is productive with each cough if I can bring sputum up it is yellowish and then by early afternoon I don't cough anymore until the next morning. I am deathly afraid that they have missed something on my chest x-ray even though it's been looked at by the radiologist and my doctor and they have assured me that I do not have lung cancer butt I'm not sure what to do at this point. They are sending me to an allergist next week. I'm very confused by my symptoms. Some days I have severe nasal congestion but it is mostly just the productive cough every morning. I do not have any weight loss or wheezing or lack of appetite. I am not coughing up any blood and other than the cough I feel pretty normal except that I need to clear my throat often. Can you please help me? I'm scared to death and I really don't want to have a CT scan because I had one last year for stomach issues and I know that cumulatively those aren't good for you either. Another odd thing is that when I start laughing the cough gets worse.

Dr. Matthew Mintz said...

Hope you get better soon. Impossible for me to offer specific medical advice over a blog without knowing you or all the details, but here are a few points based on your post that might help.
1. Chest X-ray is not likely to miss anything. They are looking for some major cause of cough that they might not hear on exam, and finding nothing should be reassuring.
2. Still sounds like this could be post-infectious cough and/or underlying asthma that gets worse with colds. Even if lung function is normal, you can still have asthma.
3. It would be extremely unusual for a non-smoking 46 year old to have lung cancer in general, but especially presenting as a cough that came out of the blue without other features like weight loss, coughing up blood.
4. You are doing the right thing by seeing a specialist (allergist). If the allergist can't help you, you may need to see a pulmonologist.
5. While CT scans do have a lot of radiation, and we should use them judiciously, if the cough doesn't go away, the risk of bad things from a second CT is much, much, lower than the risk of a persistent cough without a diagnosis.