My area of specialty is mental health and I'm stymied on finding a root cause of my chronic cough so maybe someone has suggestions.

I have no known history of any allergies or asthma. Non-smoker.

For 9 weeks I've had fairly persisting coughing. Started out as an itchy throat. No
particularly time of day is worse.

* Zero sneezing
* No fever
* Asthma test seems negative and when I try the sample inhaler nothing changes
* No stuffy nose
* No sore throat
* No watery or itchy eyes

The cough went from always dry and nonproductive to productive about 25% of the time producing incredibly THICK PHLEGM at some of those times (light yellow to light green to brownish).

Upper respiratory antibiotics did nothing. Tried prescription strength acid reducer and tums to no avail. Doctor suspected silent GERD (1/3 of cases there is no heartburn) but treatment hasn't done anything although 100% compliance is difficult. I bought a wedge pillow to sleep somewhat elevated and I did change my diet although honestly I could do even more but for 60 days I've religiously taken meds.

I tried various allergy medications (Loratadine, Zyrtec, Nasacort nasal spray)

Sinus and chest X-rays were normal.

If a food allergy why no hives or lip numbness and why would it be every day coughing every hour?
If an airborne allergy isn't it rare to not have sneezing, stuffiness, itchy / watery eyes and sore throat?

In GERD acid fumes can irritate the lungs producing mucus. Maybe I do intermittent fasting for GERD?

Possibilities include COPD, coughing from ACE inhibitors (which I take but have taken for 8 years without coughing)


To sum up:
Persistent itchy cough that is productive maybe 10-25% of the time and when productive have mucus/phlegm in about 15 - 20 occurrences per day.

Sorry for the long read

Just because you have ticks doesn't mean you don't also have fleas. No reason to think there's only one source of your cough. As far as the dry cough, it's the ACE inhibitor. Doesn't matter if you've been on it a week or 15 years. And don't switch to an ARB, either. Rookie mistake. If your sinus films were normal, but it was plain films and not a CT, you didn't get sinus films and the secretions could definitely be chronic sinusitis. Allergy eval with PFTs if persists and no response to PPI and H-2 blockers.
QED

Hoosegow said:

---

So let me understand this. You are a doctor. You've been to other doctors, but you come to TexAgs for a diagnosis?

---

I'm guessing self-diagnosis.

Edit: meant to include wink face.

stop smoking

likely the ACEi

Agree with Kool. ACEIs can cause the dry cough years after starting.

Also, if any recent URI, could be a post-viral cough/bronchitis. Though 9 weeks would be a bit long for something like that. Consider a course of inhaled steroids, like flovent. Or could go big guns and do a 7-10 days of prednisone. No taper needed for short courses. But Flovent would be better.

Start with replacing the ACEI though.

Kool said:

---

Just because you have ticks doesn't mean you don't also have fleas. No reason to think there's only one source of your cough. As far as the dry cough, it's the ACE inhibitor. Doesn't matter if you've been on it a week or 15 years. And don't switch to an ARB, either. Rookie mistake. If your sinus films were normal, but it was plain films and not a CT, you didn't get sinus films and the secretions could definitely be chronic sinusitis. Allergy eval with PFTs if persists and no response to PPI and H-2 blockers.
QED

---

I definitely appreciate the advice. I made a faulty assumption possibly that because I went years and years without coughing on an ACEI that it couldn't be that.

So 1) could the ACEI induced coughing create thick mucus? 2) If I quit the ACEI immediately how long until the coughing might go away ( assuming that's the only cause of the cough)
I really like my primary care doc but going through his nurse is typically a 48 hour torture to get back information. I'm seriously considering finding a new physician because of this falling in the crack syndrome. I mean I could just stop taking our blood pressure meds and monitor it closely if the coughing might abate quickly although I would make an attempt to go through the nurse just for giggles.

As far as sign you sinusitis goes, I've had zero face pain, no fever, my breathing is not stuffed up, no runny nose and I just did a course of Arythromiacin (Z-Pak) with zero observable change should it be bacterial.

I've been on 7 weeks of prescription strength Prilosec (omeprazole 40 mg) and added probably foolishly 150 mg of Zantac (ranitidine) the last 2 weeks.

bigtruckguy3500 said:

---

Agree with Kool. ACEIs can cause the dry cough years after starting.

Also, if any recent URI, could be a post-viral cough/bronchitis. Though 9 weeks would be a bit long for something like that. Consider a course of inhaled steroids, like flovent. Or could go big guns and do a 7-10 days of prednisone. No taper needed for short courses. But Flovent would be better.

Start with replacing the ACEI though.

---

Thank you. I tried Flovent 9 times over 2 weeks. My heart rate shot up to 122 the last time I took a puff and I'm leery now of using it and quite frankly just read up on it today and realize it's not an emergency inhaler. I mean I assume the coughing might have stopped right away by using it but it didn't.
I am way out of my field of understanding

DrHeadShrink said:

---

Kool said:

---

Just because you have ticks doesn't mean you don't also have fleas. No reason to think there's only one source of your cough. As far as the dry cough, it's the ACE inhibitor. Doesn't matter if you've been on it a week or 15 years. And don't switch to an ARB, either. Rookie mistake. If your sinus films were normal, but it was plain films and not a CT, you didn't get sinus films and the secretions could definitely be chronic sinusitis. Allergy eval with PFTs if persists and no response to PPI and H-2 blockers.
QED

---

I definitely appreciate the advice. I made a faulty assumption possibly that because I went years and years without coughing on an ACEI that it couldn't be that.

So 1) could the ACEI induced coughing create thick mucus? 2) If I quit the ACEI immediately how long until the coughing might go away ( assuming that's the only cause of the cough)
I really like my primary care doc but going through his nurse is typically a 48 hour torture to get back information. I'm seriously considering finding a new physician because of this falling in the crack syndrome. I mean I could just stop taking our blood pressure meds and monitor it closely if the coughing might abate quickly although I would make an attempt to go through the nurse just for giggles.

As far as sign you sinusitis goes, I've had zero face pain, no fever, my breathing is not stuffed up, no runny nose and I just did a course of Arythromiacin (Z-Pak) with zero observable change should it be bacterial.

I've been on 7 weeks of prescription strength Prilosec (omeprazole 40 mg) and added probably foolishly 150 mg of Zantac (ranitidine) the last 2 weeks.

---

I would probably only work on one thing at a time. The ACE inhibitor cough usually takes about two weeks to completely resolve. The literature states that the cough can take up to a couple of months to resolve. PCPs often change to ARBs, but Medscape quotes a 3-11% chance of cough with these. Quoting for Losartan:
"Cough; incidence higher in previous cough related to ACE-inhibitor therapy (3-11%)."

As far as mucous, it's possible that the chronicity of the cough has increased your secretions. With respect to chronic sinusitis, it's a bit of a different animal from acute sinusitis. The symptom of pain is less prevalent, fatigue and cough and postnasal drainage are more common. If you've tried a reasonable reflux regimen, which is what it sounds as if you have, I'd just put that to rest for now until you get off of the ACE inhibitor then re-group and look elsewhere (especially PFTs) if symptoms fail to resolve. Tessalon Perles and Mucinex-DM can help as you are waiting for the cough to resolve. And, of course, oral steroids make EVERYTHING better. Except when they make things worse.

P.S. Physician, heal thyself.
P.P.S. If you are a psychiatrist, thank you for doing that crap. Because if it were left up to me, it just wouldn't get done.
Cheers.

Never heard of Flovent causing tachycardia. Would've expected that more with an albuterol type inhaler. But just stick with dropping the ACEI and see what happens. After being on PPIs/H2 blockers for so long, I'd be a little concerned with rebound heartburn. So you might want to wean yourself off of those. And if you haven't followed the literature, PPIs used to be considered pretty safe for long term use. However new data suggests some bad long term effects. So even if there was some reflux, I'd try and solve it with diet and other lifestyle changes as best as possible first.

Thanks for the advice. I looked up Tessalon Perles and will see if my PCP will prescribe along with a non ACEI and non ARB for my BP. ACEIs seem to provide so many benefits but this cough contraindicates it's use although perhaps I could try it again someday since I went 12 years trouble free. Reading about COPD was horrifying and I sure hope that's not the case.

I wouldn't say Flovent caused the tachycardia but it was within 10-15 minutes that I felt very faint with profuse sweating and then found my HR at 122 (normally it's 90 - wish my resting HR was more like 75). I'm going to read the literature on Flovent now - it was a sample and I didn't even do the basic review.

My cousin had a persistent cough and GERD late last year. Turned out to be caused by a stomach tumor. I don't know how often those symptoms indicate stomach cancer, but still.

I would look into GERD, inguinal or hiatial hernia.... is there any correlation with eating or becoming active (like after a walk, exertion?). I saw the hernia because I have one of each and after I eat or after I am active I have a cough that won't go away for a while.. not sure why... just won't.

KG

Big Cat `93 said:

---

My cousin had a persistent cough and GERD late last year. Turned out to be caused by a stomach tumor. I don't know how often those symptoms indicate stomach cancer, but still.

---

Fo realz???
The guy is already freaked out about the possibility of COPD.

Catching either one early enough for effective treatment is the goal. My cousin only needed surgery because his case was diagnosed at an early stage, and the surgery spared a lot of his stomach, ensuring good quality of life.

Cancer has certainly crossed my mind and as everyone knows when they start surfing the web for medical diagnoses there's a lot of scary possibilities that you run across.

I truly appreciate all of the suggestions and I'm really glad that your cousin's cancer was found early! I put in another call to my physicians nurse at lunchtime. While I have good faith in my PCP and his bedside manners are outstanding the nurse I have to go through seems to take my phone calls almost as an interruption to her job. Pre-authorizations that should take 48 hours at the most have taken as long as eight days because they dropped the ball. When I asked for a follow up appointment last week they said it was going to be one month. I just want to tell them to give me his prescription pad and legal power and I'll handle it all on my own from here.

Update: Seeing my PCP today at 1:00. He called in a non-ACE inhibitor and agreed to the Tessalon Perles.

Just make sure, as above, that he doesn't put you on an ARB. PCPs do that ALL THE TIME. And keep us posted on your hopeful progress.

Update: PCP put me on a beta-blocker for hypertension and discontinued the ACEi.
PFT (pulmonary function test for lung capacity) showed me at 116% for my age/gender so no COPD or Asthma. Xrays were unremarkable.
Took TESSALON PERLES 200mg
(benzonatate) at bedtime with no apparent cough relief.
Doc says he's 95% sure it's the ACE inhibitor causing problems - could take 2-4 weeks to eliminate cough. I've been ACE inhibitor free for 72 hours and no definitive change in coughing yet.
Phlegm/mucus sample sent for analysis and will know by Monday/Tuesday some results (bacteria, blood present etc.)
Cancelled allergy consult to see if coughing abates in the next 2 weeks secondary to discontinued ACEi

Thanks once again for all of the input everyone has provided.

Thanks for the follow up. I think he is right. Best of luck with this. You may notice a significant exercise intolerance with a beta blocker. If that happens, there are other choices as well.

Which beta blocker? And did he say why that over a calcium channel blocker? Keep us updated. Hopefully it's just the ACEI.

Cough doesn't seem changed after 17 days off of the ACE inhibitor. Don't know why PCP picked a beta blocker.

A patient of mine (an MD) recommended this guy (pulmonologist):

https://www.healthgrades.com/physician/dr-timothy-connolly-

but the appointment is in Late July!!!

Any recommendations for Houston / The Woodlands pulmonologists would be helpful.

In addition, I found out I'm anemic. Hemoglobin is 11. Stool sample will happen Monday.

Any weight loss?

My FIL had a persistent cough + weight loss and it was lung cancer.

Yes, actually 12 pounds in 4 months. I've had 2 X-rays without obvious tumors but upper right lobe has higher density and yes lung cancer is part of the differential still.

Any of that intentional weight loss? Or can you attribute it to anything like a busy schedule and skipping meals, or anything to that effect? Not being a smoker, and assuming no history of toxic exposures in the past, lung cancer is unlikely, but not impossible. The anemia and weight loss is a little bit concerning if it can't be explained by diet.

If you want reassurance one way or the other, I think they do low dose CT scans for lung cancer screening in people with heavy history of smoking.

Even at 17 days, still could be the ACEI though.

And your chest xray was a PA and lateral right?

The weight loss was not intentional which is disturbing however there is a twist to this. I was prescribed a low dosage of Adderral for the first time due to some suspected mild inattentive type ADHD that I long suspected.
As expected my appetite tanked but an addition twist is I didn't take it that often and being off ADHD meds for 6 weeks my appetite isn't what it usually is so I am concerned about the weight loss. I'm discontinuing ADHD meds indefinitely until my health crises abates as it's not that "necessary" and I'm not a fan of psychotropics. (Yes, my username is shocking).
You're correct about the X-rays. I have smoked cigars in the past and not lightly for a few years but never cigarettes. No smoking for 8 months as I lost interest. I exercise strenuously with high weight / low rep weight training x 5 years (4 days/week) but no cardio to speak of. It helped condition me but I avoided cardio fearing muscle loss. Rather shortsighted in hindsight but I was obsessed with trying to bench 300 (I know). I'm definitely going to focus on a LOT more cardio when my coughing ends.

I'm sure my connection can get me in to see "a" pulmonologist but I prefer this Dr Connolly. Perhaps I can hound them on getting in if there are cancellations. At 3 months 1 week the appointment is a lifetime away (hopefully not a pun).
At times I get that gurgling and have a productive mucus mother load and surprisingly in just 4 minutes there's another productive nasty thick slimy round 2, then 3,4,5,6 ... like where is this coming from ... then no cough for maybe an hour then dry cough for an hour then productive. No stuffy nose or sneezing or typical allergy symptoms ( i've never have been known to have allergies so this is a guess)

catarrh

https://en.m.wikipedia.org/wiki/Catarrh

Yeah, I think a pulmonologist might be your best bet at this point. Even if there's nothing going on but a prolonged recovery from ACEI induced cough, he'll be able to put your mind at ease that nothing else is lurking.

I think there's a possibility that something in the abdominal cavity can irritate the lung bases, causing cough. Normally unlikely, but if you're anemic, and have a loss of appetite, just poke around for your spleen. If you can feel it, mention that to your doc.

You definitely need to see a pulmonologist and have PFTs done, plus or minus have a CT of the chest. You could see an ENT in the interim and have an office nasal endoscopy plus flexible fiberoptic laryngoscopy to rule out other sources of the cough. Don't screw around. Best to you.

I just found this thread, sorry for your struggles sounds terrible.

I agree with ENT and sinus CT scan, this sounds like chronic sinusitis to me and a z pack is not at all adequate. The intermittent productive cough in my mind argues against a bronchopulmonary mass causing the chronic cough. Inhaled foreign body would be on the differential as well but odd at your age.

With the anemia and weight loss if the ENT evaluation is negative I would push for chest and abdominal imaging. Chronic infection can cause anemia and weight loss but if you cannot find it then time to search for malignancy.

Did any of your blood work include ESR or CRP?

Pulmonologist here.

You need a CT of the chest to rule out bronchiectasis, a mass, or findings consistent with an atypical infection that would not be covered with usual antibiotics.

Though you've been on maximal reflux therapy this does not rule out GERD/silent aspiration as the culprit. CT chest may find a hiatal hernia which would bring GERD to the top of the differential, but this is not the definitive tests and you would need other workup.

Also would have put you on 10 days of prednisone a long time ago.

Good luck, keep us updated.

Oh and make sure you bring the results of your PFTs to your pulmonology appointment (if he/she is not on the same EMR as your PCP).

Edit: I'm also not too concerned about your anemia or weight loss. In the causes of chronic cough (esp in the absence of hemoptysis), lung cancer is low on the differential. Still need a CT to make sure.

I'm seeing an allergy specialist Monday. Test probably will be ordered. Tuesday morning a gastroenterologist to schedule a colonoscopy and throat/stomach scope and Tuesday afternoon seeing an otolaryngologists (ear/nose/throat) with expectations of a scope that same day. Pulmonologist appointment is July 24.

Nothing has changed. Phlegm seems more pinkish/brown (blood?) but not obvious bright red or super obvious that "I'm coughing up blood." Coughing activity unchanged. Elevated calcium caused ionized calcium test which was normal. PHT and Phosphorus test normal.

I put myself on double strength Nexium 4 days ago. I'm trying to be aggressive with this. Doc said without knowing why there is bleeding - blood in fecal sample - that prednisone could make bleeding worse. Not sure if low iron anemia (21 with normal range being 59-158) and low ferritin (11 with normal range 30-400) is connected to the coughing.

Definitely doing the right things. Other than doing PFTs, I'm not sure how much the allergist will really add. If you can't get in to see the pulmonologist until that far away, any of the doctors you are seeing, or your PCP, needs to order a chest CT. Upper and lower endoscopy is a must as well.