Persistent cough in a young woman

Published on 10/04/2015 by admin

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Problem 32 Persistent cough in a young woman

Richard A. Stapledon

A 37-year-old woman of Caucasian origin presents with an irritating cough of 3 months’ duration and recent episodes of small amounts of blood-stained sputum. She is a non-smoker. She has consulted her family doctor twice during this period and has had only a modest response to successive courses of antibiotics. She has also noticed some lethargy and more recently occasional night sweats.
On examination she appears mildly unwell, has evidence of recent weight loss and a temperature of 38.2°C. No other abnormal findings were elicited.

Q.1

What further history should be obtained?

You question the patient further. Five years ago she spent 2 years as a volunteer teacher in Malawi. When she returned she underwent TB screening and had a ‘positive’ tuberculin skin test and a normal chest X-ray. At the time, the clinic placed her on a 6-month course of isoniazid preventive therapy, which she had apparently completed.

You arrange a chest X-ray. The PA and lateral views are shown in Figures 32.1 and 32.2.

image

Figure 32.1

image

Figure 32.2

Q.2

What does the chest X-ray show? What might the findings suggest? Would any other imaging be of help?

Q.3

What simple investigation would you request urgently? Are there any other investigations that may assist in making the diagnosis?

Your suspicions have been aroused, and you admit her to an isolation ward for investigation and treatment. Later, your lunch is interrupted by a call from the microbiology laboratory advising that the smear from her sputum is heavily positive for acid-fast bacilli (AFBs).

Q.4

Why does this result necessitate an urgent call? What should you do now? What additional investigations are indicated?

Q.5

What treatment would you recommend initially and why? What are the main treatment concerns?

Q.6

Are there any other issues that you need to address promptly?

Your patient is surprised and concerned that she is sick, and wants to know if this could have been prevented.

Q.7

Could this illness have been prevented?

Answers

A.1 A careful history in a patient with persistent cough and haemoptysis may provide clues about a possible diagnosis before any definitive investigations are undertaken.

Causes include:

• Lung abscess/pneumonia.
• Bronchiectasis.
• Active tuberculosis (TB).
• Mycetoma.
• Lung cancer (e.g. carcinoid).
• Chronic bronchitis.
• A-V malformation.
• No cause is found in up to 30% of cases.

This patient’s fever and night sweats strongly imply an infective cause. The more chronic nature of her history suggests that tuberculosis must be excluded. Disease caused by a non-tuberculous mycobacterium can present a similar clinical picture to TB but in this instance is considered less likely to be the causative agent. Lung abscess or malignancy would also seem less likely. You need to specifically enquire about any TB risk factors:

• Known close contact with a TB case (especially family).
• Past residence or visits to a high-risk country for an extended period, including India, Asia, Africa and Aboriginal and Torres Strait Islander people(s).
• History of previous treatment for TB disease or ‘preventive’ treatment for latent TB infection.
• Causes of immunosuppression such as HIV infection, immunosuppressive medications particularly TNF agents and steroids.

A.2 The chest X-ray shows a cavitating lesion in the left upper lobe, with some air space opacity in slightly contracted upper lobes.

These chest X-ray findings are highly suspicious of post-primary TB disease, especially in this clinical context. However, no chest X-ray pattern is absolutely diagnostic. Lung malignancies need to be considered and may also co-exist.

TB disease that follows primary infection can produce lower zone infiltrates, hilar or mediastinal lymph node enlargement or pleural effusions. More varied and less specific features can be seen in up to a third of cases, particularly the elderly and immunosuppressed. This can include those of primary disease, a miliary pattern, solitary or multiple nodules or even ‘normal’ chest films. Remember, TB is the ‘great mimicker’.

The radiological changes seen so far are highly suspicious of pulmonary tuberculosis and a CT scan is unlikely to provide any more definitive information. The CT scan is more sensitive than the standard chest X-ray in the examination of the lung parenchyma, mediastinum and pleura. It may be useful in those patients with less obvious or atypical features, or suspicion of other diagnoses such as cancer.

A.3

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