A 45-year-old man comes to the emergency department due to "coughing up blood." The patient had an episode of harsh coughing this morning and then noticed streaks of bright red blood in his sputum during subsequent coughs. The patient has had 3 weeks of nasal congestion and progressive cough, which now awakens him from sleep. He has no chronic medical conditions. Vital signs are normal. The patient is well-appearing and in no acute distress. The nasal mucosa is boggy, and the posterior oropharynx is erythematous. The lungs have a few scattered crackles, and heart sounds are normal. Laboratory results are as follows: Which of the following is the most likely diagnosis in this patient?

Question

A 45-year-old man comes to the emergency department due to "coughing up blood."  The patient had an episode of harsh coughing this morning and then noticed streaks of bright red blood in his sputum during subsequent coughs.  The patient has had 3 weeks of nasal congestion and progressive cough, which now awakens him from sleep.  He has no chronic medical conditions.  Vital signs are normal.  The patient is well-appearing and in no acute distress.  The nasal mucosa is boggy, and the posterior oropharynx is erythematous.  The lungs have a few scattered crackles, and heart sounds are normal.  Laboratory results are as follows:  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d285_97fa_bc81_e50b365574af_MD0003_00 This patient's persistent, vigorous cough, posttussive hemoptysis, and peripheral lymphocytosis raises strong suspicion for infection with Bordetella pertussis, a highly contagious gram-negative bacterium transmitted by respiratory droplets. Although young, unvaccinated children are at greatest risk for severe disease, approximately 50% of cases occur in adolescents and adults. B pertussis has tropism for the ciliated epithelium of the upper respiratory tract. Following attachment, the pathogen releases cytotoxins that denude and damage respiratory epithelium, leading to a stepwise illness, as follows: Catarrhal phase (weeks 1-2) - symptoms (eg, malaise, cough, conjunctival infection, excessive lacrimation) are nonspecific.Paroxysmal phase (weeks 2-8) - ciliated epithelium damage causes microaspiration of oral secretions and results in paroxysms of vigorous coughing, often worse at night (wakes patients from sleep). The classic posttussive emesis is frequently absent in adults; however, denudation of respiratory epithelium occasionally leads to hemoptysis after coughing spells. Most patients otherwise feel fairly well.Convalescent phase (weeks 8-12) - the cough slowly begins to improve. After 3 months, most cases are resolved. Catarrhal phase (weeks 1-2) - symptoms (eg, malaise, cough, conjunctival infection, excessive lacrimation) are nonspecific. Paroxysmal phase (weeks 2-8) - ciliated epithelium damage causes microaspiration of oral secretions and results in paroxysms of vigorous coughing, often worse at night (wakes patients from sleep). The classic posttussive emesis is frequently absent in adults; however, denudation of respiratory epithelium occasionally leads to hemoptysis after coughing spells. Most patients otherwise feel fairly well. Convalescent phase (weeks 8-12) - the cough slowly begins to improve. After 3 months, most cases are resolved. Symptoms are less severe in adolescents and adults, but pertussis should be suspected in patients with persistent (>2 weeks) cough and either: paroxysmal cough; inspiratory whoop; or posttussive emesis. Lymphocytosis (toxin-induced) is often an important diagnostic clue. Confirmation can be made by respiratory culture or PCR testing. (Choice A) Allergic bronchopulmonary aspergillosis can cause hemoptysis, but almost all cases occur in those with underlying asthma or cystic fibrosis. In addition, eosinophil count, not lymphocyte count, is generally elevated. Patients also generally have bronchial obstruction, expectoration of brownish mucous plugs, and low-grade fever. (Choice B) Aspiration pneumonia often causes subacute pulmonary symptoms and can sometimes lead to hemoptysis. However, most cases occur in patients with periods of altered sensorium (eg, alcoholism, drug abuse, seizure disorder) or swallowing dysfunction. Lymphocytosis and nasal congestion are atypical, and sputum is often foul-smelling. (Choice C) Influenza can cause nasal congestion and cough, but it typically also causes fever and myalgias and resolves within 5-7 days. (Choice E) Tuberculosis often presents with subacute or chronic cough and can occasionally cause hemoptysis. However, fever and other systemic manifestations (eg, anorexia, fatigue) are usually present, and nasal congestion is atypical. Educational objective: Pertussis often occurs in adolescents and adults. It generally manifests as a stepwise illness that begins with 1-2 weeks of nonspecific symptoms and then progresses to several weeks of the classic paroxysmal cough. Adults often do not have the classic posttussive emesis. Most cases resolve within 3 months.

A 45-Year-Old Man Comes to the Emergency Department Due to "Coughing