Kardos P
Gemeinschaftspraxis und Pneumologisches-allergologisches Zentrum, Maingau Krankenhaus, Frankfurt a.M.
Pneumologie. 2001 May;55(5):249-52. doi: 10.1055/s-2001-13942.
In non-smokers the underlying causes for chronic persistent cough (CPC) e.g. chronic cough without diagnostic chest X-ray or pulmonary function test--are usually as follows: several common upper airways diseases, bronchial (cough type) asthma, gastrooesophageal reflux or treatment with an ACE (angiotensin converting enzyme)--inhibitor. In 10% of CPC however the cause remains uncertain. We report a 30 year old non-smoker with severe coughing and repeated vomiting for two months. No laboratory or technical data could be collected suggestive of a common cause of CPC: Upper airways disease, bronchial flow limitation or hyperresponsiveness, ACE inhibitor medication, B. pertussis infection, gastrooesophageal reflux disease (by 24 hours pH-probe) were ruled out. Fiberbronchoscopic findings remained unremarkable, except for the bronchial biopsy specimen, which showed moderate eosinophilic inflammation of the mucosa and marked thickening of the subepithelial layer. Since the cough was non-productive, sputum induction with 3 ml nebulised 3% NaCl solution was performed. 28% of the granulocytes were eosinophil stained. A low quality morning sputum (< 1 ml) showed 21% eosinophilia. Thus, the diagnosis of eosinophilic bronchitis was established. 400 micrograms budesonide dry powder inhalations b.i.d. for one week resolved the cough, treatment was stopped after three weeks. No recurrence was seen two months later. Both the cough type asthma and the eosinophilic bronchitis could represent a form fruste of classical bronchial asthma beyond wheezing or dyspnoea, but with the common main symptom: cough. Since hyperresponsiveness and cough are phenotypic hallmarks of cough variant asthma, in eosinophilic bronchitis--beside cough--another two features of asthma are present: eosinophilic inflammation of the mucosa along with sputum eosinophilia and subepithelial layer thickening. Not surprisingly, eosinophilic bronchial inflammation could be shown in patients with cough variant asthma as well, who--up to 56% during a four year-period--develop classic asthma. The long-term outcome of eosinophilic bronchitis is not known, however. Thus, asthma, cough variant asthma and cough due to eosinophilic bronchitis can mirror different phenotypes or phases of the same entity. CPC due to either the cough type asthma or the eosinophilic bronchitis is like asthma fast responding to inhalative steroids. (Induced) sputum staining should be added to the diagnostic armamentarium of CPC.
在不吸烟者中,慢性持续性咳嗽(CPC)的潜在病因,如无诊断性胸部X线或肺功能检查的慢性咳嗽,通常如下:几种常见的上呼吸道疾病、支气管(咳嗽型)哮喘、胃食管反流或使用血管紧张素转换酶(ACE)抑制剂治疗。然而,在10%的慢性持续性咳嗽患者中,病因仍不明确。我们报告一名30岁的不吸烟者,严重咳嗽并反复呕吐两个月。未收集到提示慢性持续性咳嗽常见病因的实验室或技术数据:上呼吸道疾病、支气管气流受限或高反应性、ACE抑制剂用药、百日咳杆菌感染、胃食管反流病(通过24小时pH监测)均被排除。除支气管活检标本显示黏膜中度嗜酸性炎症和上皮下显著增厚外,纤维支气管镜检查结果无明显异常。由于咳嗽无痰,用3毫升雾化的3%氯化钠溶液诱导痰液。28%的粒细胞为嗜酸性染色。一份低质量的晨痰(<1毫升)显示嗜酸性粒细胞增多21%。因此,确诊为嗜酸性支气管炎。每天两次吸入400微克布地奈德干粉,持续一周后咳嗽缓解,三周后停药。两个月后未见复发。咳嗽型哮喘和嗜酸性支气管炎都可能是典型支气管哮喘在喘息或呼吸困难之外的一种顿挫型,但有共同的主要症状:咳嗽。由于高反应性和咳嗽是咳嗽变异型哮喘的表型特征,在嗜酸性支气管炎中,除咳嗽外,还存在哮喘的另外两个特征:黏膜嗜酸性炎症以及痰液嗜酸性粒细胞增多和上皮下增厚。不足为奇的是,咳嗽变异型哮喘患者也可出现嗜酸性支气管炎症,在四年期间,高达56%的患者会发展为典型哮喘。然而,嗜酸性支气管炎的长期预后尚不清楚。因此,哮喘、咳嗽变异型哮喘和嗜酸性支气管炎引起的咳嗽可能反映同一疾病的不同表型或阶段。由咳嗽型哮喘或嗜酸性支气管炎引起的慢性持续性咳嗽对吸入性类固醇反应迅速,如同哮喘一样。(诱导)痰液染色应纳入慢性持续性咳嗽的诊断方法中。
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