Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at LSU (Shreveport) Department of Allergy and Immunology
A 37-year-old female with allergic rhinitis on immunotherapy comes to the allergy clinic with symptoms of dry cough and heartburn for 3 weeks. She has had this type of cough off and on for the last 2 years. The patient was treated with Prilosec 1.5 years ago with good effect but she stopped the medication after 4 months due to "bloating." She would like to receive her immunotherapy shot today.
Past medical history (PMH)
Flonase (fluticasone), Zyrtec (cetirizine).
Two years ago.
Pulmonary function tests (PFTs)
Normal, 1 year ago
Started 5 months ago, last dose was 4 weeks ago. Grass and tree extracts were used.
Dog and cat, the family also has horses and chicken.
What is the reason for the cough?
Most likely GERD.
What would you do?
The patient was prescribed Nexium and advised to return to the clinic in 2 weeks.
Would you give the scheduled immunotherapy injection today?
It is generally advisable to postpone the administration of the immunotherapy injection until acute symptoms resolve. If the patient's symptoms worsen after the injection, it would be unclear what the cause was: GERD or anaphylaxis.
Which animal is "worse" for pollen-allergic patients - cat or dog?
A typical cat spends most of his/her life indoors and although cat hair has a higher allergic potential than dog hair, cats are less important than dogs for patients with pollen-related allergies. Many dogs, on the other hand, roam outside every day and get back home with "a suit of tree, grass, weed and mold."
Differential diagnosis of cough, a simple mnemonic is GREAT BAD CAT TOM. Click here to enlarge the image: (GERD (reflux), Laryngopharyngeal Reflux (LPR), Rhinitis (both allergic and non-allergic) with post-nasal drip (upper airway cough syndrome), Embolism, e.g. PE in adults, Asthma, TB (tuberculosis), Bronchitis, pneumonia, pertussis, Aspiration, e.g foreign body in children, Drugs, e.g. ACE inhibitor, CF in children, Cardiogenic, e.g. mitral stenosis in adults, Achalasia in adults, Thyroid enlargement, e.g. goiter, "Thoughts" (psychogenic), Other causes, Malignancy, e.g. lung cancer in adults).
What did we learn from this case?
GERD is a common cause of cough in patients with allergy in the absence of asthma. It is prudent to await the resolution of acute symptoms before immunotherapy is resumed.
Treatment Options for Allergic Rhinitis (click to enlarge the image).
In patients with asthma and chronic productive cough, polymorphonuclear (PMN) neutrophil leukocytes in sputum suggest:
(C) presence of a foreign body
(D) exercise-induced asthma
(E) extrinsic asthma
Correct answers: A, B, C
PPIs Not Recommended for Routine Treatment of Adult Asthma - in patients with "silent" GERD. Medscape, 2011.
Insufficient evidence to recommend empirical use of PPIs for routine treatment of asthma. Arch Intern Med. 2011;171(7):620-629.