Should computed tomography and bronchoscopy be routine examinations for chronic cough?

Chronic cough is a common symptom of many diseases. Guidelines on cough from different countries recommend chest X-ray as the first-line examination. However, as compared to computerized tomography (CT), chest X-ray is insensitive in the diagnosis of many diseases. We speculate that CT is more helpful in excluding the causes of long-term cough, such as bronchial tumors and pulmonary interstitial diseases, which prevents patients from receiving unnecessary examinations and diagnostic treatments for chronic cough. In addition, a single chest CT is safe and affordable in some regions. Therefore, chest CT may be recommended as a first-line examination for patients with chronic cough. In addition, although bronchoscopy is employed as a further examination for chronic cough, it plays an important role in the diagnosis of chronic cough, especially in rare bronchial diseases such as amyloidosis and foreign body inhalation. Induced sputum cytology was not accepted as a necessary examination for chronic cough, but it becomes a first-line examination until physicians recognize that non-asthmatic eosinophilic bronchitis is a common cause of chronic cough. Therefore, we speculate that the roles of chest CT and bronchoscopy in the identification of causes of chronic cough are increasingly important; in some regions, or for patients suspicious for uncommon causes of chronic cough, CT and bronchoscopy are recommended as first-line examinations.

IgG4-related fibrosing mediastinitis diagnosed with computed tomography-guided percutaneous needle biopsy: Two case reports and a review of the literature

RATIONALE

Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory disease characterized by elevated serum IgG4 levels with infiltration of IgG4+ plasma cells and severe fibrosis in affected tissues. Recently, idiopathic fibrosing mediastinitis (FM), an extremely rare fibroinflammatory disorder, has been recognized as a form of IgG4-RD. As IgG4-RD can be treated by glucocorticoids, identification of the etiology of FM by surgical biopsy is essential; however, mediastinal biopsy is often difficult. We report 2 cases of IgG4-related FM successfully diagnosed with computed tomography (CT)-guided percutaneous needle biopsy.

PATIENT CONCERNS

Case 1 was a 66-year-old woman with elevated serum C-reactive protein without any symptoms and case 2 was 78-year-old woman with abnormal mediastinal contour on chest x-ray. By further work-up, both cases were found to have mediastinitis accompanied by elevated serum IgG4. CT-guided percutaneous needle biopsy revealed massive infiltration of IgG4+plasma cells along with storiform fibrosis.

DIAGNOSIS

IgG4-related FM.

INTERVENTIONS

Glucocorticoid therapy.

OUTCOME

The treatment resulted in significant improvement of the lesions after 3 months.

LESSONS

Early recognition and diagnosis of IgG4-related FM is essential because a delay in appropriate treatment initiation leads to progressive fibrosis with irreversible organ damage and poor prognosis. Our cases highlight CT-guided percutaneous needle biopsy as a promising option for histological examination in patients with IgG4-related FM.

An 84-Year-Old Man With Progressive Dyspnea and an Abnormal Chest CT Scan

CASE PRESENTATION

An 84-year-old man without a history of smoking presented with progressive dyspnea of 6 months' duration accompanied by fatigue and unintentional weight loss. He denied fever, chills, chest pain, hemoptysis, rash, joint pains, or muscle aches. He had multiple hospitalizations for similar presentations that were diagnosed as pneumonia. History was significant for diastolic heart failure, hypertension, and type 2 diabetes mellitus.

Evidence-based Evaluation and Management of Chronic Cough

Chronic cough is common and has a significant impact on the wellbeing of patients and the use and cost of health care services. Traditionally the approach to chronic cough in patients who are nonsmokers and are not taking an angiotensin-converting enzyme inhibitor has focused on the diagnosis and management of the upper airway cough syndrome, asthma, and reflux disease. The evaluation of patients with chronic cough frequently involves trials of empiric therapy for these 3 conditions. Chronic cough may be perpetuated by abnormalities of the cough reflex and sensitization of its afferent and central components.