CHRONIC COUGH-ANOTHER UNUSUAL CAUSE

     I have seen many patients with complaints of chronic cause.I often make a joke when I say," Your cough and cold is my bread and butter". So I see many patients with the complaints of cough.When these patients are nonsmokers and their chest X-ray is OK , most of the time it is due to one of the 3 causes,Asthma,or allergies with post nasal drip or gastroesophageal reflux.So most of the time I worked them up for one or all three and treat as therapeutic trial and they get better.But sometimes I come across unusual cause for the cough.So this one was one of the unusual cases.
       I had seen this relatively young lady , may be about 55 years old.She was young but had long history .She was complaining of chronic cough.When I got in to details of the history, she told me that she was non smoker and had bad pneumonia and then had very stormy course.She was on respirator and could not be weaned off the respirator and so needed tracheostomy.Then she was diagnosed with a condition called POLYMYOSITIS . In this condition the muscles get very weak and this is related damage to the muscles by own body and the treatment is with steroids and immuno-suppressants. So she was started on the steroids , and then switched to immuno suppressants got better and was off the prednisone . Her cough was there when she had pneumonia and though the pneumonia got better, the cough continued. She was treated with different medicines. Her X-ray was OK.I was thinking in terms of ASTHMA, as the steroids can suppress the asthma and when the steroids are taken off the asthma can flair up. But due to be on immunosupressants I did CT scan of the chest.The CT scan showed some damaged bronchi and some scars.The were most likely due to previous pneumonia. But I was concerned and so I decided to do bronchoscopy to make sure there was no unusual infection.
     The surprise came when I did the bronchoscopy. She was coughing significantly in spite of quite a bit of sedation. When I entered the Trachea, her coughing would get worse. There was a abnormal tissue growth just bellow the vocal cord ,with 2 green colored threads coming out from it . It was so close to the vocal cord that I could not do any biopsy.I thought that It was related to the tracheostomy. It looked like there was some retained sutures and it had caused the excessive tissue growth.AND THIS MOST LIKELY WAS THE CAUSE  OF THE COUGH !!