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Having cough. Not cured by antibiotic. Started body pain and rashes on leg. What is causing this?

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Practicing since : 1979
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Hello Doctor,
My wife has a persistent cough for nearly 3 months now. She is 30 years, married and do not have any prior medical complications. She has a healthy food habit and also no smoking and no drinking of alcohol.
- 3 months back (middle of march), on some day, she started with a dry cough and body ache. GP prescribed her an antibiotic, that did not help her. We went to GP again, she prescribed another antibiotic but the cough did not improve much.
- After some days her ankle, knee and fingers started to pain and the ankle portion started swelling. Few days later she got skin rashes (small) around the leg. The rashes were not raised bumps but black in color. Meanwhile she started getting mild fever, around 101 degrees.
- We went to the doctor who suggested an x-ray and also normal blood tests. x-ray and blood tests came out clean but he directed us to a rheumatologist, who inspected her legs and prescribed her calcort (deflazcort) for 1 month. Meanwhile he took the blood samples also for testing Sarcoidosis. He also did a CT scan of her chest.
- Now this is in the 4th week from the begining. The ACE test for Sarcoidosis came negative and the Rheumatologists directed us to Pulmonologists.
- Her swelling in the leg and ankle started to come down and also the pain, but not the cough. It stayed mild but persistent. It was mostly dry with occasional phlegm. Now the pulmonolgist did some spirometry tests and inspected her CT scan. He asked us to continue with the Calcort for the full course and keep updating him every week.
- Now this is in the 2nd month from the beginning. The cough stayed mild but persistent, we kept on updating the pulmonolgist every week. From last 3 weeks, she is vomiting white clear phlegm and we kind of hear whistling sound in her lower respiratory tract while breathing in during the cough. The Doctor advised for a test on bacterial infection which also came negative.
- So now as it stands, we do not know what is going on.
- She has lost 8 kilos since these 3 months and is relatively week. She is going about her routine but not with great enthusiasm
- The cough flares up especially in the evening and when she eats something, and when there is change in environment.
- Additionally 2 weeks before she had the start of this infection, I was having an infection with a swollen throat but that got cleared with the antibiotics in few days.

I would like to know your general opinion and also some queries from my side
- Is Sarcoidosis be still a cause, eventhough test result are indicating otherwise.
- Could a bacterial/viral infection persist this long. Her test results for this is negative though.
- What are the other possible causes. She is not exposed to any TB since it is non existant here. Also her phlegm color seems to not indicate any thing in that direction.
- We are originally from India but are staying abroad from few years.

Let me know if you need further information.
Posted Fri, 13 Jul 2012 in Lung and Chest disorders
Answered by Dr. Shashi Dangwal 18 hours later


Thank you for posting a detailed query on XXXXXXX I shall try to provide you with necessary information pertaining to your query.

From your description it is clear that your wife is suffering from chronic cough for which there can be many causes. In her case the causes could be cough variant asthma, sarcoidosis, collagen vascular diseases, Gastroesophageal reflux disease (GERD), Laryngopharyngeal Reflux (LPR) or even tuberculosis. You have not mentioned her Computed Tomography (CT) scan and pulmonary function test (spirometry) reports here. The reports would have been helpful to understand her problem.

1. Angiotension Converting Enzyme (ACE) level is not the only test to diagnose sarcoidosis. If the reports are suggestive of sarcoidosis then she has to continue steroids (calcort) and even the dose may have to be increased till her symptoms are controlled and then they can be tapered off to the minimum effective dose.

2. If the above tests are normal, then she should be investigated for tuberculosis and other (aforementioned conditions). Tuberculosis is a very common cause of persistent cough in developing countries and you are originally from India.

3. I would suggest you get back to her pulmonologist. A bronchoscopy should be done and fluid and tissue from lungs should be obtained and examined. This may be of great help in arriving at a diagnosis and ruling out many other diseases. Even if tuberculosis tests are negative, she still can be given a trial of anti tubercular drugs (ATT) - this is called "empirical ATT trial". If she improves in a month's time than ATT can be continued for a total of 6 months, otherwise it can be stopped.

In addition I also suggest you to consult a rheumatologist, gastroenterologist as well as ENT surgeon to rule out all other conditions. There can be instances when more than one condition might be causing her symptoms and each need to be treated independently.

4. In the meanwhile, discuss with her pulmonologist about adding a long acting beta agonists inhalers like salmetrol or formetrol, a monteleukast and a proton pump inhibitor drugs if she is not already taking them yet. They can be beneficial to her.

5. As far as bacterial or viral infection is concerned, apart from tuberculosis I do not think she has an infection as she doesn't have fever and other prodromal symptoms which commonly accompany an infection.

Hope I was able to address all your concerns. Let me know if you need any other information, I will be glad to help her.

Wish her a speedy recovery

Best Regards
Above answer was peer-reviewed by
Follow-up: Having cough. Not cured by antibiotic. Started body pain and rashes on leg. What is causing this? 11 hours later
Hello Doctor,

Thanks for your opinion. I have attached some reports for further inference. Before going through the report, some additional information.

- The reports are in french but I guess you can make out most of the contents.

- The phlegm color in the report is mentioned brown-red, but that was due to the tea and banana she had before vomiting the phlegm. She gets a clear white phlegm otherwise.

- The Doctor here has given Inuvair for inhaling from yesterday.

- As observed by you regarding TB, Doctor here was looking at that angle to begin with, but since then he has ruled that out since her overall condition has improved markedly with anti inflammatory drug like calcort and also some medical reports did not indicate in that direction.

- She is generally in good health but for the cough. It flares up especially in the night and early in the morning and when she eats.

- I could not attach the CT scan, but the pulmonologist here suggested nothing of substance to be worried about.

- Also Spirometry tests were done twice in the space of 7 weeks. Both the reports were similar and there was no improvement nor deterioration. So the Doctor is of the opinion that the infection is not spreading. He suggested there is still some inflammation because the report is indicating a reduced lung capacity.
Answered by Dr. Shashi Dangwal 15 hours later
Thanks for further inputs regarding your wife`s health.
I' m glad that your doctor does not think that she could be suffering from TB. In view of normal CT Scan but slightly impaired spirometry (though the report provided is not complete), I am of the opinion that she has a kind of asthma called cough variant asthma. However I would still suggest that Gastro Esophageal Reflux Disease and Laryngo Pharyngeal Reflux be ruled out.
Above answer was peer-reviewed by
Follow-up: Having cough. Not cured by antibiotic. Started body pain and rashes on leg. What is causing this? 2 days later
Hello Doctor,

Thanks for the reply. Just to follow up on some new developments, my wife has started with fever and chills from last couple of days. It is going upto 102 degrees. This is strange since most of these past weeks she never used to have such a high fever. Her cough seems to have got reduced but not completely gone. Some questions and updates

- She stopped calcort 10 days back, could the fever be because of the waning out of its effect?.

- She is taking ibuproffen from last 2 days whenever she is getting a fever, is that OK to continue with that whenever she gets a fever.

- For possibility with Sarcoidosis, can this kind of fever keeps coming and going.

- She had given another blood test last weekend and she is awaiting the results from that. Do you think it would be a good idea to get another x-ray done.

- Just to follow up on Tuberculosis, considering her normal chest x-ray and normal blood count, could it still be a possibility. I read somewhere that white blood cells count will be abnormal for any kind of infection even including TB. Her cough was never so severe and also it did not increase all through these weeks and additionally its waning out from last few days.

- We are quite concerned at this point with this and if you suggest some more tests to be done, I will take that additional suggestion to the specialist here.

- Additionally, can she take meftal spas (for period pains) along with ibuproffen since she might have her periods now.

- We had another visit last week to the specialist and I will update him tomorrow with the current status for taking this issue forward. He checked her oxygen concentration in blood through an instrument and also listened to her lungs and found everything normal.

I appreciate your valuable input.

Answered by Dr. Shashi Dangwal 49 minutes later

Regarding the new development of moderately high grade fever with chills, a bacterial infection needs to be ruled out since she has been on oral steroids for some time and superadded infections are known to occur. Get a routine blood count and a chest x-ray done. She may be given a course of antibiotics after consulting her pulmonologist.

Ibuprofen can be taken for fever. If she is taking meftal spas for periods it will take care of fever as well and there won`t be any need for ibuprofen though both can be combined if fever doesn’t come down. However, it should not be done every time to avoid the unnecessary excess use of pain killers.

Though not very common but sarcoidosis may be associated with fever which is generally low grade.

As far as TB is concerned, it always remains a possibility for any undiagnosed cough and fever. If routine tests like blood counts, x-ray chest, sputum tests and Montaux test are normal, you may go in for TB Elisa, TB Quantiferron Gold, Bronchoscopy and if required a higher possibility along with cough variant asthma.

I would suggest that please do not rush her into more and more tests at short intervals and give her time to respond after one line of treatment has been started.

Above answer was peer-reviewed by
Follow-up: Having cough. Not cured by antibiotic. Started body pain and rashes on leg. What is causing this? 5 days later
Dear Doctor,

Continuing with the follow up and the second opinion.

I have attached a chest x-ray of 2 days back. Some findings and questions

- Seems like the Doctor has picked up an infection in latest chest x-ray, a localized infection and in comparison with the first one. Can you let us know anything about that, I have uploaded it.

-We are in continuous consultation with the specialist here and he has prescribed antibiotics (zinnat 500) for 10 days, 2 per day.

- What I am worried now is, she has the fever nearly 102-103 for last week almost. She is taking antibiotics from 2 days and there is no let up in fever so far. Should we need to wait and see?. The fever raises in the morning and also in the evening.

-She had stopped oral steroids last week itself and her blood report was normal, that was just before fever started.

- She feels like vomiting after she eats and her cough also increases. She vomits out clear white phlegm but in small amount. The cough will generally be dry.

I appreciate your continued advice.

Thanks and Regards
Answered by Dr. Shashi Dangwal 22 hours later

Thanks for further inputs regarding your wife’s health.

I really could not appreciate any definite evidence of any lung infection in the chest x XXXXXXX uploaded by you. Only her lower lung fields appear little more hazy than normal. However, I feel that you should continue the antibiotics prescribed by your doctor. Give her some thing for her fever, gastritis and vomiting and let her rest.

As suggested by me earlier, if her symptoms continue, she should undergo a bronchoscopy and the fluid and tissue so obtained should be subjected to various tests. Possibility of sarcoidosis or even TB remains.

I wish her speedy recovery.

Above answer was peer-reviewed by
Follow-up: Having cough. Not cured by antibiotic. Started body pain and rashes on leg. What is causing this? 21 hours later
Thanks for the continued advice and I appreciate your help

Few things for my clarification, before I go ahead and discuss the possibility of bronchoscope with the specialist here.

- you mentioned TB, but can TB have such a dry cough for this prolonged time. Her chest x-ray between 3 months majorly did not indicate any change. Her initial CT scan did not give any clues in that direction. Also she has a whistling sound coming from her air waves, could that be more like an indication of air wave inflammation. Of course one things going in that direction is high fever. Also the initial symtomps started with swelling and pain in joints and rashes but responded well to calcort.

- also can dry air and weather here influence the inflammation?. because I am planning to get her back to India where there is a better weather and also for further consultation after seeing for next few days. Do you think that is a good option.

- the main concern now is the fever and seems like antibiotics isnot reducing the cough and fever and it is almost 4th day do it. Do you think I should discuss the possibility of changing the antibiotic to something strong with the Doctor.

Sorry that I am trying to drill it down a bit further because I want to zero in on the cause with further inputs.

I appreciate your continued help.

Best regards
Answered by Dr. Shashi Dangwal 3 hours later

Regarding your query about TB being the cause of your wife`s cough, as I had mentioned earlier that though at present it doesn’t look like TB, one always has to entertain the possibility - especially in third world countries and she being from India. In fact at times a trial of anti tubercular treatment (ATT) is given when no cause can be found for cough and this is called empirical ATT (as again mentioned by me earlier).

Dry cough and wheezing sound go more in favour of sarcoidosis or cough variant asthma; but since her symptoms are persisting despite treatment with steroids more investigations need to be done and bronchoscopy is one of them.

You may feel more at home back in India and some times change of place also helps.

Hope I have answered all your queries.

Above answer was peer-reviewed by
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