Medical Articles

That Iritating Cough!!

Initial presentation

  • Male patient mid 30’s previously healthy
  • Severe ”fllu” (Swine Flu) followed by
    • Persistent dry cough
    • Ankle oedema
    • Dysrhythmia
    • SOB
    • Night Sweats
    • Decreased effort tolerance
    • Arthralgia

Workup

  • ECG : Normal
  • Urine : analysis Normal
  • FBC : Normal
  • CRP : Raised (27)
  • LFT : Normal
  • TFT : Normal
  • Cardiac echo : Normal

Working Diagnosis

  • Post influenza irritable airways
  • Treatment
    • Prednisone 20mg dly 2/52
    • Zithromax 500mg twice weekly 2/52
  • Respose
    • Resolution of dysrhythmia, paedal odema,night sweats, arthralgia and SOB
    • Marked improvement in cough

Further Workup

  • CXR
    • Hilar adenopathy
    • Patchy lung infiltrate
    • Right pleural effusion
  • CT Chest
    • Confirmed hilar lymphadenopathy
    • Peribronchial infiltration
    • Right sided effusion
  • Lung functtons
    • Normal
  • Mediianoscopy
    • Biopsy of mediastinal lymphadenopathy

Sarcoidosis

  • Multisystem granulomatous inflammatory disease characterized by non-caseating granulomas
  • Etiology
    • Unknown
    • Theories include infectious, environmental and genetic.
  • Pathophysiology
    • Granulomatous inflammation characterized primarily by accumulation of monocytes, macrophages and activated Tlymphocytes, with increased production of key inflammatory mediators
    • Paradoxic state of simultaneous hyper- and hypo- activity is suggestive of a state of anergy
    • Dysregulated calcium metabolism with hypercalcaemia and hypercalciuria

Epidemiology

  • Incidence: 16-60/100 000
  • More common in Northern Europeans and North American Blacks..
  • More common in non smokers
  • Presentation differs by population
    • Blacks – Pulmonary fibrosis
    • Japanese – Cardiac (5% mortality)
    • Irish/Icelandic – Löfgren’s syndrome

Staging

  • Chest X-ray changes are diiviided iinto four stages
    • Stage 1 bihilar lymphadenopathy
    • Stage 2 bihilar lymphadenopathy and reticulonodular infiltrates
    • Stage 3 bilateral pulmonary infiltrates
    • Stage 4 fibrocystic sarcoidosis typically with upward hilar retraction, cystic & bullous changes

Löffgren’s Syndrome

  • Acute Sarcoidosis
  • Triad of hilar adenopathy, arthralgia and erythema nodosum with or without fever.
  • Presentation differs in men and women
    • Men: Ankle oedema and arthralgia predominant
    • Women: Erythema nodosum predominant
  • Imparts better prognosis with >90% of patients in remission at 2 years.

Treatment

  • Observe
  • Prednisone
  • Immune suppression

Prognosis

  • The disease can remit spontaneously or become chronic (>3 year history), with exacerbations and remisions. In some patients, it can progress to pullmonary fibrosis and death.
  • Approximately half of the cases resolve or can be cured within 12–36 months and most within 5 years.
  • Some cases persist several decades
  • Patients with sarcoidosis appear to be at significantly increased risk for cancer, in particular lung cancer, malignant lymphomas, and cancer in other organs known to be affected in sarcoidosis