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Case report: Chronic cough

Article  in  Revue medicale de Bruxelles · August 2012

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Tuesday, October 23, 2007
Pleural Disease, continued
factors predispose this heterogenous group of HIV-negative, HHV8
negative patients to developing PEL.
CONCLUSION: HHV8-negative, EBV-positive malignant effusion
lymphoma in non-HIV patients is a rare but emerging entity that
necessitates further clinicopathological study.
REFERENCES:
1. V. Ascoli et al. Body cavity lymphoma. Curr Opin Pul Med. 2002:
8:317-322
2. Y. Matsumoto et al. Human herpesvirus 8-negative malignant
effusion lymphoma: a distinct clinical entity and successful treat-
ment with rituximab. Leuk Lymph.2005;46;(3):415-419
DISCLOSURE: Nisha Rathi, No Financial Disclosure Information;
No Product/Research Disclosure Information
AN APPARENT TENSION PNEUMOTHORAX CAUSED BY JEJU-
NOSTOMY TUBE MECHANICAL ILEUS WITH PARAESOPHA-
GEAL HERNIA
Joyce N. Gonzales MD* Thomas A. Dillard MD, FCCP Sherman
Chamberlain MD, FACP Albert Chang MD Medical College of Georgia,
Augusta, GA
INTRODUCTION: A 60 year old white man was transferred from a
medicine ward to Medical Intensive Care Unit (MICU) because of acute
respiratory distress, marked anxiety, tachycardia (pulse 158), and in-
creased blood pressure to 213/103. These events occurred three days after
laparoscopic placement of a jejunostomy feeding tube under general
anesthesia followed by attempts to initate feedings. A portable chest x-ray
revealed marked over-aeration of the left hemithorax, with no lung
markings, and mediastinal shift to the right. There was no pleural line
visible. The patient had a life-long history of mental retardation and
kyphoscoliosis. Prior chest x-rays revealed thoracic deformity and eleva-
tion of the left hemidiaphragm. A para-esophageal hernia was recognized
but the risk of surgical correction was considered prohibitive at that time.
CASE PRESENTATION: His recent medical history consisted of a
lengthy hospital stay in MICU for pneumonia and respiratory failure. He
received a tracheostomy for inability to wean from mechanical ventilation
despite multiple trials; however, he was successfully weaned after trache-
ostomy. Laparoscopic jejunostomy was performed three days earlier to
allow removal of a nasoduodenal feeding tube. Mechanical ventilation was
resumed on arrival to ICU with some stabilization. Vital signs on morning
rounds while sedated on the ventilator were: Pulse 130, Blood pressure
130/70, respiratory rate 15, temperature 36.8 C. Arterial blood gases
revealed mild to moderate respiratory acidosis. Breath sounds were absent
in the left chest. The left chest and abdomen were tympanitic on
percussion. The on-call surgical resident had recommended placement of
a thoracostomy tube for a suspected pneumothorax. The patient remained
tachycardic but maintained blood pressure. Tube feedings were stopped.
An emergency chest CT scan was obtained which revealed marked
distention of the stomach and proximal small bowel, with near complete
occupation of the left hemithorax. See scout film Figure 2. There was
extensive retained gastric fluid as well. Due to extreme distention, and
difficulty with prior attempts to place a nasogastric tube, the Gastroen-
terology service was consulted to perform urgent endoscopy for the
purpose of decompressing the stomach. A gastric decompression tube was
then inserted under direct vision. These interventions resulted in im-
provement in vital signs with gradual return to baseline. Revision of the
jejunostomy feeding tube was performed. Use of the jejunostomy tube
was successfully instituted several days later.
DISCUSSIONS: The present case represents a rare example of
gastrothorax with respiratory distress simulating tension pneumothorax
resulting from mechanical ileus in the presence of a paraesophageal
hernia. The patient’s congenital and acquired deformities undoubtedly
contributed to his morbidity. The complications of paraesophageal hernia
include incarceration with gastrointestinal obstruction, bleeding and
perforation. Respiratory compromise may result from aspiration, abscess,
and increased gastric volume as in this case.
CONCLUSION: Tension gastrothorax is usually a complication of total
intrathoracic stomach. Emergency thoracocentesis or tube thoracostomy
for this condition are contraindicated due to risk of complications such as
bowel perforation, sepsis, empyema, acute lung injury and respiratory
failure. The preferred inital treatment, as in this case, is gastric decom-
pression. Clinicians should consider the diagnosis of gastrothorax in
situations of respiratory compromise in patients with congenital abnor-
malities, as in this case, prior to attempting a thoracostomy placement,
which would likely lead to adverse outcomes.
View publication stats
REFERENCES:
1. Bamgbade OA. Management of Tension Gastrothorax. Resuscita-
tion Vol 70, 2:293-294
2. Scott CT, Burton JH. Intrathoracic Stomach Presenting as Acute
Tension GastrothoraxAm J Emerg Med 1999; 17:370-371
DISCLOSURE: Joyce Gonzales, None.
Pulmonary Conundrums
4:15 PM - 5:45 PM
CASE REPORT: A CHRONIC COUGH MYSTERY
Louella B. Amos MD* Diana R. Quintero MD Medical College of
Wisconsin, Milwaukee, WI
INTRODUCTION: Chronic cough is a common pediatric medical
complaint defined as daily symptoms lasting more than 4 weeks. The
cough is usually associated with asthma, gastroesophageal reflux disease,
post-nasal drip syndrome, environmental irritants, or recurrent aspiration.
We report an unusual case of persistent cough as the primary manifesta-
tion of a Chiari I malformation.
CASE PRESENTATION: The patient’s birth and past medical history
were uneventful until he was 9 months of age when he developed a
chronic, non-productive cough. The cough was present throughout the
daytime and nighttime, both during and between feedings. It was
refractory to inhaled corticosteroids, bronchodilators, and antibiotics. On
examination, he appeared content without obvious distress. His physical
exam, including his cranial nerve exam, did not reveal significant abnor-
malities. Sweat chloride test, chest radiograph and chest CT were
unremarkable. Upper gastrointestinal series was negative for reflux or
anatomic abnormality. Bronchoscopy revealed normal vocal cords and
airway anatomy. Cytology from the bronchoalveolar lavage revealed
numerous neutrophils and moderate lipid laden macrophages. Tracheal
ciliary biopsy was normal. Swallow evaluation with videofluoroscopy
showed silent aspiration when the patient became agitated. A magnetic
resonance imaging of the brain and cervical spine demonstrated caudal
descent of the cerebellar tonsils to C2 consistent with a Chiari I
malformation and syringohydromyelia through most of the spinal cord.He
underwent posterior fossa decompression, and within one month of
surgery his cough had almost completely disappeared. Five months later,
a swallow evaluation still revealed the presence of aspiration, but his
cough remained absent.
DISCUSSIONS: In Chiari I malformation, the cerebellar tonsils
herniate through the foramen magnum into the upper cervical spine,
which may produce symptoms of occipital or posterior cervical pain.
Brainstem compression may manifest as laryngeal sensory loss, vocal cord
paralysis, dysphagia and recurrent aspiration pneumonia; therefore,
chronic aspiration due to diminished laryngeal sensation is one possible
etiology of our patient’s persistent cough. Surprisingly, he had persistent
CASE REPORTS
aspiration during a swallow assessment five months post-decompression,
but his cough had resolved soon after his surgery, suggesting that there
may have been a neurologic cause for our patient’s intractable cough. The
brainstem is thought to be the integration center that transmits impulses
to the effector muscles for cough. We propose that the brainstem
compression in our patient may have been directly linked to his persistent
cough.
CONCLUSION: This case shows that decompression of the Chiari
malformation treated our patient’s chronic cough. One likely explanation
is that his swallow function improved, decreasing the frequency of
aspiration events and subsequently his cough. However, the persistent
aspiration on an objective swallow study months after resolution of cough
suggests that brainstem compression from the Chiari I malformation may
have a direct association with our patient’s persistent cough. To our
knowledge, this phenomenon has not been reported in the medical
literature.
REFERENCES:
1. Chang, AB. Cough, Cough Receptors, and Asthma in Children.
Pediatric Pulmonology 1999;28:59-70
2. Canning BJ. Anatomy and Neurophysiology of the Cough Reflex,
ACCP Evidence-Based Clinical Practice Guidelines. Chest 2006;
129:33S-47S
DISCLOSURE: Louella Amos, No Financial Disclosure Information;
No Product/Research Disclosure Information
CHEST / 132 / 4 / OCTOBER, 2007 SUPPLEMENT 705S