When a common cough turns nasty

Cough is a common presentation to a to a GP clinic. At initial presentation, most patients are quite correctly treated, for a viral illness, an asthma attack, reflux or sinusitis etc. It is a hard to decide if the cough is of sinister aetiology. However, there are some warning signs that may give an indication:

Case 1: A female patient in her mid-fifties had presented to her GP with a cough of 3 weeks. She was a non-smoker and had no other medical co morbidities. There was no evidence of reflux, sinusitis or signs of infection. She had minimal white sputum production. Patient was given antibiotics for a possible chest infection and requested to come back in 4 to 6 weeks. At 6 weeks, the cough had not resolved and the GP suggested a CXR at this point, but the patient was reluctant. She opted for another course of antibiotics and CXR if failure to improve. Finally, 12 weeks from the time of onset of cough, she ended up having a CXR which demonstrated a large left sided apical lung mass with metastasis to the liver and adrenal gland. There was tumour invading to the lower trachea causing irritation and cough. I performed an EBUS biopsy, that confirmed the primary lung cancer. 

THE RED FLAG here is a cough that didn’t have a strong precipitating cause and not improving despite empiric treatment. Also, remember that up to 20% of Non-Small Cell Lung Cancers occur in never smokers.

Case 2: My patient this time was a female in her mid-sixties with a background history of well controlled asthma. She was a nonsmoker. She had developed a cough over the last 2 weeks and seen her GP and was treated as an asthma exacerbation. The patient had progressively worsened cough with now development of shortness of breath. A CXR followed by a CT chest was reported as “likely intestinal lung disease suggestive of UIP’. The GP discussed this patient with me due to the patient’s rapidly worsening symptoms. Whilst waiting to see me the patient was admitted to hospital with sub-acute bowel obstruction. She was managed conservatively and a polyp in the colon had been biopsied demonstrating adenocarcinoma. The patient presents to my clinic the day after discharge from hospital and to my surprise was extremely short of breath with oxygen saturations of 83% on air. The CT chest did not look like UIP to my eyes as a Respiratory Physician and my doubts were confirmed by the hospital Radiologist. She had a EBUS biopsy of an enlarged mediastinal LN that confirmed adenocarcinoma spread from a bowel cancer. The patient in fact had lymphangitis carcinomatosis that was misinterpreted as lung fibrosis on the CT scan. The radiological pattern of lymphangitis can mimic UIP or sarcoidosis and the clinical history and progression aids the diagnosis. 

THE RED FLAG HERE: is the rapid progression.