The Challenge: Can you figure out what is wrong with a previously healthy 75-year-old woman with a cough that just won’t quit?
Every month the Diagnosis column of The New York Times Magazine asks Well readers to take on a difficult case and offer their solutions to a diagnostic riddle. This month’s case revolves around a lively, elderly woman — a patient of mine — who suddenly develops a cough that persists and worsens over the course of several months. I’ll provide you with the notes, labs and imaging that amassed over the half a year it took to come up with an answer.
The first reader to provide the correct diagnosis gets a signed copy of my book “Every Patient Tells a Story” and the satisfaction of solving a case that had me pulling my hair out for weeks.
The Patient’s Story:
“Dr. Sanders, I’m still sick.” The slender 75-year-old woman shook her head sadly. “I hate to be a bother, but you’ve got to help me with this cough. It’s just about killing me.”
Her face was pale; there were dark smudges beneath her eyes, and she’d lost a lot of weight. Whatever she had, if it wasn’t killing her, it certainly was making her sick.
The Patient’s History:
Her problems had started a few months earlier. She’d come in to see me with a simple cough. It had started with a cold, but that infection was long gone and all that remained was this cough.
It was strange, she told me back then. She’d be fine during the day, with the occasional cough — but at night, when she lay down, it was unbearable. Indeed, she had slept in a chair the past two nights because in bed she kept waking up to cough.
Then, the day before, she’d had this strange pressure in her chest during one particularly forceful paroxysm. That scared her enough to pick up the phone and make an appointment to see me. It must have been quite a fright, since I usually saw her no more than once a year. It wasn’t that she didn’t like me, she told me the few times I’d seen her in the past; she just didn’t like doctors.
Although she was worried at that initial visit, I wasn’t. Her report that she’d spent the past couple of nights sleeping in a chair might have been a concern in some of my patients, since one sign of heart disease is this inability to lie down flat, but this woman had no risk factors for heart disease other than her age. She didn’t smoke — and never had. And she was in great shape. At 75 she had no medical problems; she ate right, and she exercised almost every day. She was one of my healthiest patients.
Her physical exam was normal that first visit. So was her EKG. I figured she probably had some leftover bronchospasm from a resolved upper respiratory infection. Or maybe this was bronchitis. So I gave her an inhaler to calm her twitchy airways and a short course of antibiotics, and I really expected the cough to disappear.
But the cough persisted. Indeed, each time she returned to my office or talked by phone over the next few months, her cough was just a little bit worse and she was a little sicker. None of the tests I’d ordered were particularly revealing, and none of the medications I had prescribed had helped. She was starting to get frustrated, and so was I.
In the Exam Room:
Seeing her now, I was more than frustrated; I was worried. She’d lost a lot of weight. Her normally thin face looked gaunt, and the fat that normally pads the temples and forehead was gone. Her eyes were tired and puffy. And she couldn’t get more than a few words out before a new paroxysm of coughing cut her off.
She couldn’t sleep, she told me between bursts of her barking cough. And she had no appetite. Even when she was hungry, the constant coughing made eating almost impossible. She had a new symptom as well: abdominal pain.
On exam, once again, I found nothing. She had no fever. Her lungs were clear. There were no enlarged glands suggesting an unresolved infection. Her abdomen was soft and had no tenderness. However, now when she coughed, dark yellow mucus came up. Whatever she had, it was clearly getting worse.
“Can’t you give me something for this cough?” she asked me once more.
The Most Common Symptom:
Cough is the most common single reason for a visit to a primary care doctor. Most of the time it’s caused by an upper respiratory infection or cold. But that type of cough usually resolves on its own. A persistent cough — like my patient’s — was a different story. It had many possible causes. The most common was some kind of environmental allergy. I treated her with antihistamines. They didn’t help.
Heartburn (also known these days as reflux) can also cause a cough, as the acid from the stomach irritates delicate tissues never designed to withstand it. I tried a couple of different types of anti-acid medications. They didn’t help either.
She said she never wheezed, but she did have some chest tightness and on occasion felt short of breath. Was this asthma? I gave her another inhaler. It didn’t work any better than the first one.
Those three diagnoses — allergies, reflux and asthma — were why most people kept coughing, most of the time. She clearly didn’t have what most people had. So what was left?
Could it be lung cancer? She had never smoked, but 10 to 15 percent of those who are found to have lung cancer didn’t smoke. Could this be tuberculosis? She had traveled throughout rural Central America decades earlier, so she could have been exposed.
A chest X-ray might have shown either of those diseases — but didn’t. In fact, it was completely normal. So was a second one, done weeks later when she still was no better.
I sent her for pulmonary function tests. The report said her lungs weren’t exactly normal, but the technician commented that her constant coughing made the test difficult to interpret. You can read the pulmonary function test report below.
The Right Test:
ACT scan of the patient’s lungs, with a magnification on the right.
Now she was back in my office, sicker than ever. I was frustrated and starting to get nervous. Her weight loss was worrisome. And she had this new abdominal pain.
I had already referred her to a gastroenterologist to look for any evidence of reflux or even a malignancy. She was to get scoped the following week.
In the meantime, I sent a sample of her purulent sputum to the lab to culture. When those results were also unrevealing, I decided to get a chest CT — and finally, finally found something abnormal.
Throughout the right lung there were areas of scarring and what is known as bronchiectasis, a particular type of scar tissue where the elastic component of the delicate airways appears stretched out and dilated, like a floppy waistband of a much-washed pair of shorts. (Bronchiectasis is visible in the area of magnification.)
Now I was worried and confused. Worried because this kind of lung injury made a patient prone to getting more infections. And confused because it wasn’t at all clear to me how this patient got it in the first place. Bronchiectasis is usually seen in patients who have a long history of serious lung infections. And this woman had had pneumonia a couple of times in the past decade, but otherwise nothing. I had an answer, a diagnosis, but not one that made sense. At least not right away.
It took me some time to figure it out, but I finally did.
What about you? Can you figure out what this woman had? And what test would you order to confirm it?
Friday June 7 3:08 p.m. | Updated Thanks for all your responses! You can read the correct answer at “Think Like a Doctor: A Cough Solved!”
Rules and Regulations: Post your questions and diagnosis in the comments section. The correct answer will appear Friday on Well. The winner will be contacted.
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