Resolved question:
Dear Expert Life Savers,
I would like to share about my mom's health condition who is currently 60 years old. In the year 2008, she got first heart attack. She is a heart patient who is currently undergoing medical management without any heart surgery. After couple of years, it has been identified pathologically with tubercloma in brain(left side). She was successfully operated for the treatment of tubercloma in brain by neuro-surgeon. Everything went on well except a new ailment that came up as a bye-product of surgery and it's COUGH.
Since the operation, she has been coughing continuously. She took many medications since 2 years but of no effect. She keeps on coughing through out the night. After two years, doctors suggested for blood and CT scan.
Below are the reports of CT Scan. Kindly request to pls. suggest what to be done.
DEPARTMENT OF RADIOLOGY
CT SCAN OF CHEST WITHOUT CONTRAST
TECHNIQUE:
Helical CT acquisition of chest was done on Dual source Dual energy 64 slice MDCT scanner & images were reconstructed in axial & coronal planes. Images were documented in mediastinal & lung windows.
FINDINGS :
Tracheobronchial wall calcification noted.
Aorta and coronary arterial atheromatous calcification noted.
Cardiomegaly noted.
Scattered areas of subpleural fibrosis with reticulations and fuzzy pleuroparenchymal interface in bilateral lungs fields. No honey combing - Early ILD features.
Trachea and major bronchi are normal.
Mediastinal structures appear normal.
No evidence of pleural effusions.
Visualised bones & soft tissues are normal.
For clinical / lab parameters (PFT) correlation.
Rgrds,
Ata
Submitted:
4 Days
Category:
Pulmonologist
Hello,
Thank you for your consult at DoctorSpring.com.
I realize that your mom has a cough, and that is obviously troublesome, and persists in-spite of adequate treatment. I presume the blood investigation gave the same result as of CT - inconclusive.
In the process of trying to help you out, I would need more information -
Is there any periodicity for your mother's cough? any diurnal variation or postural variation?
Is there associated fever? breathlessness/ wheezing sound?
Is it exagerated by any particular object - animate/ inanimate?
do you have pets / birds at home?
Is there any weight loss?
Is the cough producing sputum?
and finally, but most importantly - Is your mother on any medicine like Enalapril/ losartan for heart failure? ( Angiotensin converting enzyme inhibitors( medicines for hypertension / heart failure ending in _ pril / or angiotensin receptor blockers ( ending in _sartan)?
Please reply as follow-up.
Regards
Dr. Jacob George P
MD, FCCP.
Dear Doctor,
at the outset, thanks for your reply. Pls. find below answers to all your queries.
It's true that blood investigations gave the same result so as CT for lungs.
1) Is there any periodicity for your mother's cough? any diurnal variation or postural variation?
Ans-)There is nothing as such but it's continuous cough. It gave as Intestitial Lung Disease. Her frequency of couging is every 30-40 seconds she cough and tries to take out sputum. Once the sputum goes off, she might get a gap of hardly 1 minute and then starts coughing. Morning times I have noticed it's more.
2) Is there associated fever? breathlessness/ wheezing sound?
Ans-) Sometimes fever comes which I could say once in two weeks. Breathing is normal besides doctor suggested to take fresh oxygen so he asked to buy "MEdi-Oxy" (a device which produces oxygen). There is no wheezing sound as she is not an Asthma Patient.
3) Is it exagerated by any particular object - animate/inanimate?
Ans-) Nothing as such but we have noticed whenever an intake of cold water, cough gets exagerated. The story of coughing starting after brain TB surgery. Earlier, she was normal.
4) do you have pets / birds at home?
Ans-) NO, not even Air-Condition nor carpets.
5) Is there any weight loss?
Ans-) No. We have noticed weight gain since last year.
6) Is the cough producing sputum?
Ans-) YES, the colour of sputum is WHITE.
7) Is your mother on any medicine like Enalapril/ losartan for heart failure?
Ans-) None of the above mentioned. She takes below list of medicines:
a. CLOPITAB - A 150
b. RANOLAZ 500mg
c. ROSUVAS 10
d. TORSINEX-20
e. MONOTRATE SR 30
f. DERIPHYLLIN RETARD 150
Other than the above medication, there is nothing she is using for heart.
Looking forward for your reply at the earliest...
Regards,
Ata
Hello,
Thanks for your reply, and regards from our team.
There is a huge lacunae in what a treating doctor at patient side can diagnose and what suggestions an online doctor can make. However, you have provided an excellent history and associated factors to help me narrow down.
1. A reactive airway disease ( including asthma is out) as the history suggests that cough is not exacerbated by seasons/ dusts/ any particles that can cause allergy. Hence I wonder the need of deriphyllin - that too in a patient with heart disease!
2. As there is no associated fever, no yellow sputum - infections can also be safely ruled out.
3. Drug as a cause of cough - I don't find a culprit there also. The cough has started post surgery, but I believe that it was just a coincidence.
4. Now what remains - an occult acid- reflux disease, causing irritation of throat, and your mother may not be aware of. The same can be precipitated by clopitab also. What we can try is a drug that suppresses acid secretion and also helps in pushing stomach contents down. Example will be rabeprazole along with levosulpride / domperidone.
Please note this is not a diagnosis, but a trial and error method which seems really innocuous. Along with the above, a cough suppressant - such as levocloperastine / dextromethorphan also may be tried.
5. Lastly - the writing on the wall - ( which i fear, I wont be able to help) - is ILD. I had ignored the CT diagnosis of interstitial lung disease as that term itself is vague ( something like telling a place in Sahara), and also it was mentioned early changes - which I hope are non specific changes with any disease. However, it seems that your doctor has already suggested home oxygen - which means she is having features and symptoms of low oxygen - a feature of established ILD. The cough in ILD in that case is intractable to treat many a times, however the steps are same as i mentioned already. And for maybe that reason deriphyllin is on your drug list.
I would suggest to avoid spicy food, avoid lying down immediately after sleep, and try taking dextromethorphan, along with rabeprazole and domperidone/ levosulpride.
Hope this will work. Please feel free to get back if you have any queries.
Regards
Dr. Jacob George P
MD FCCP
Dear Doctor,
Do you advise for below medication? If yes, then pls. advise the dosage as well.
dextromethorphan,
rabeprazole & domperidone / levosulpride
Hello,
The tablets for cough- dextromethorphan, ethyl morphine etc may not be available as over the counter medications because of their abuse liability. Also in elderly we have to adjust the dose according to side effects- mainly constipation, dry mouth, sedation and hypotension. The usual dosage of ethyl morphine will be 16 mg tablet half thrice a day - increase to one thrice a day.
Ddose of dextromethorphan will be 15 mg thrice a day, escalated upto 90 mg a day. It will be available as over the counter medicine in form of cough syrups, more often than tablets. In that case we will have to see the constitution per 5 ml syrup and adjust dose accordingly.
The daily dose of rabeprazole is 20 mg once daily or maximum twice daily, taken half an hour before food.
Levosulpride is taken in empty stomach as 25 mg thrice a day / 75 mg sustained release once a day.
Domperidone dose will be 20 mg twice a day , half hour before food or in combination with rabeprazole, as a 30 mg sustained release.
I advise to take the medicines only after a written prescription in consult with a family physician. However, this should help you get an idea about doses.
Regards
Dr. Jacob George P
MD, FCCP
Hello,
The tablets for cough- dextromethorphan, ethyl morphine etc may not be available as over the counter medications because of their abuse liability. Also in elderly we have to adjust the dose according to side effects- mainly constipation, dry mouth, sedation and hypotension. The usual dosage of ethyl morphine will be 16 mg tablet half thrice a day - increase to one thrice a day.
Dose of dextromethorphan will be 15 mg thrice a day, escalated upto 90 mg a day. It will be available as over the counter medicine in form of cough syrups, more often than tablets. In that case we will have to see the constitution per 5 ml syrup and adjust dose accordingly.
The daily dose of rabeprazole is 20 mg once daily or maximum twice daily, taken half an hour before food.
Levosulpride is taken in empty stomach as 25 mg thrice a day / 75 mg sustained release once a day.
Domperidone dose will be 20 mg twice a day , half hour before food or in combination with rabeprazole, as a 30 mg sustained release.
I advise to take the medicines only after a written prescription in consult with a family physician. However, this should help you get an idea about doses.
Regards
Dr. Jacob George P
MD, FCCP
Dear Doctor,
Do you advise for below medication? If yes, then pls. advise the dosage as well.
dextromethorphan,
rabeprazole & domperidone / levosulpride