Help with a puzzling long-term post-nasal drip mystery

August 17, 2018 3:35 PM

For over 2 months I've been battling a persistent post-nasal drip, chest and lung congestion. After visiting a few doctors, I am at a crossroads in understanding what direction to go next. While I understand AskMeFi members cannot offer medical advice per se, I'd be grateful for suggestions or ideas, for example on types of specialists and tests. (Specifics on the situation are inside. I have no insurance and little money, so my decisions on treatment have a major impact financially.)

Several weeks ago, I had a productive and continuous chest cough (day and night); the nostrils remained clear for the most part, but a tickle of post-nasal drainage was making its way into the chest, silently and steadily. This lasted for about 3 weeks before I visited a doctor. A chest x-ray supposedly ruled out pneumonia, and that doctor said it was likely a normal cold virus which will run its course, so they didn't prescribe antibiotics.

Several days later, still coughing, I decided to get a CT scan and visit a pulmonologist. He was a good specialist and contradicted the previous doctor, diagnosing me with bacterial pneumonia (he showed it to me on the CT result), and asthmatic bronchitis. I also ended up with pleurisy due to the weeks of hard coughing. He prescribed me two antibiotics (azithromycin and ), prednisone (steroids), and an inhaler (albuterol sulfate) for the asthmatic bronchitis. I took all medication as directed.

Within about 5 days my cough had abated. The post-nasal drip stopped somewhere within the first week, or at least I didn't notice it anymore. There was no longer a wheezing feeling deep in the lungs when taking a deep breath, as I had had previously.

Now, nearly 2 weeks after finishing the medication, symptoms are slowly starting to come back. One of my housemates developed strep throat (tested via swab) and she might have gotten it from me, but I'm not sure because I didn't have a swab done.

At first I noticed a gradually increasing throat congestion in the past 10 days. Then it progressed into a minor post-nasal drip. Very rarely is either nostril blocked, however. Whatever this is, it seems to be targeting the throat, chest and lungs while bypassing the nostrils for the most part.

Now, in the past 2 or 3 days, an intermittent deeper cough has started up. Sputum color became a little more yellow (whereas in the past 2 weeks it was at first clear, then white).

I decided to try some over-the-counter remedies: pseudoephedrine (Sudafed) and Allegra (antihistamine) to see if this could thin and dry out the secretions, hopefully preventing any potential for the pneumonia to return. But this only helps a little, and isn't really slowing down the steady progress towards greater symptoms. Meanwhile I've been focusing on exercise, sunlight, sleep and nutrition, just to try and help the immune system do its job. It doesn't seem to be allergies though. I've had seasonal allergies and it mostly involved sneezing and congested nose, none of which has happened during these months. Also, I've recently been tested for HIV and tuberculosis, both were negative.

So, at this point I need to make a decision, and this is where it gets interesting and confusing. Here are the options, as I see it:

1. Wait it out ... (Could lead to dangerous pneumonia recurrence)
2. Visit a regular MD and ask for a throat swab -- they'll prescribe more antibiotics if it's shown to be bacterial infection i.e. strep
3. Visit an ENT specialist, to check on other potential causes of prolonged post-nasal drip, such as polyps in the nasal cavity.
4. Visit another pulmonologist and get a sputum lab test. (Apparently pneumonia can also be caused by fungi and viruses in the lungs, not just bacteria, so the sputum test would help narrow it down.)
4b. I could also get another CT scan, in order to determine whether the pneumonia detected earlier is still in place.

Would another round of antibiotics (and maybe steroids) really knock this out? Or could it just come back again afterward again? Obviously pneumonia is nothing to mess with -- people get hospitalized and even die from it, so I hear.

Without insurance, each test comes out of my meager budget, but I can potentially borrow from family members. I just want to choose the most effective course of action. It seems like I have to take educated guesses about the cause (i.e. self-diagnose to some extent) in order to avoid spending a lot of money on unnecessary specialists and tests. (For example, I haven't had a lung cancer screening in many years, but I guess the recent CT scan would have shown it?) My body just feels less strong to fight this, than in younger years, as I'm about to turn 46 and as a programmer have been sedentary for too long.

Also, I live most of the year in Costa Rica. There is a lot of mold and fungus around; it grows on the walls, laundry, shoes, etc. It's possible that some fungus has taken hold in the lungs, and perhaps the pulmonologist misdiagnosed it as bacterial pneumonia, when in fact it was fungal. (But what do I know?) Hence the idea of a sputum test to find out what's going on.

I've been using a neti pot and steam inhalation regularly, in case there is something that can be flushed out of the sinuses through those methods, but it hasn't seemed to make much difference.

I've also read that among the bacteria that can cause pneumonia is Chlamydia Trachomatis. I did test positive for chlamydia a couple of years ago, but although the symptoms went away after antibiotic treatment, I've also read that it can go dormant and reactivate years later when conditions in the body are conducive to that.

Finally, there is the question of parasites. I've had pinworms and possibly other parasites (i.e. flukes and whipworm) at some point in the recent past. I actually saw the pinworms moving in the toilet, so I can be sure of that much. Although I've used various herbal, holistic and pharmaceutical methods to fight them, I'm not 100% sure if they are gone. I've done a ton of reading and research on worms and parasites since then, and joined some message boards where sufferers discuss their symptoms and treatment. It seems that there is a distinct possibility for some intestinal worms to migrate away from the colon, into areas such as the lungs, throat, eyes and nose. Microscopic eggs may even be deposited in the nose via the fingers, and hatch within the sinuses.

Now, this is not widely known information, and most doctors minimize the possibility of worm migration in areas outside the colon. However, published research exists showing proof that this can and does happen. And many people in the parasite communities online have documented that they experienced these migrations, although they have often been told it's delusional parasitosis (which is the standard response from the medical community, it seems).

I have personally experienced feelings of movement in my eyes and nose, especially during the times when the pinworm activity was at its highest. The last time this happened was several months ago. But I do ask myself whether there might be microorganisms, nematodes, flukes, etc. somewhere in my sinuses or throat, by their presence causing the post-nasal drip to remain for so long. It's difficult to adequately test for parasites even with stool, urine and blood samples, let alone if they have migrated to other areas.

So, if you've read this far, I greatly appreciate you taking the time to read this. And I'd be grateful for any suggestions, ideas and thoughts, with the understanding that all answers are purely speculative and for entertainment purposes, not to be construed as medical advice.

posted by TreeHugger to Health & Fitness (13 answers total)

Response by poster: There is also a possibility of "lipid pneumonia" which comes from taking fats or oils into the lungs. I did some cannabis oil pen vaping within the past couple of years, not often but from time to time. I was a pot smoker for quite some years as well, but never a dedicated cigarette smoker. Currently I avoid all of it except on rare occasions. It makes me wonder whether the pulmonologist even had a way to be sure whether it was viral, bacterial, lipid, fungal, etc. as a sputum test wasn't done. Maybe he took a well-educated guess?
posted by TreeHugger at 3:59 PM on August 17, 2018

You should not need to figure out which body systems your symptoms are coming from yourself; this is what your GP is for. See one you trust (or one who is highly recommended by people you trust), and ask them to walk through the differential diagnosis with you. If they are unable to diagnose or treat you themselves, they will refer you to the appropriate specialist.
posted by TheLittlestRobot at 5:03 PM on August 17, 2018

Don't overthink this. I'm a pharmacist and in my experience sometimes an antibiotic just doesn't work. Different antibiotics hit different bugs and if what you've got isn't susceptible to the antibiotic you were prescribed, you will need to try another one. The doctor expects you to come back if the first one doesn't work. Unfortunately a lot of people who don't have insurance don't want to come back because that gets expensive. But it really is what you should do.

I think it's super unlikely that you have parasites or lipid pneumonia. I think it is WAY more likely that you just happen to have a bacteria that's resistant to what you were prescribed. That happens all the time, and also respiratory infections can last a super long time. It sucks, but it is worth it to go back and get a different antibiotic.
posted by selfmedicating at 5:19 PM on August 17, 2018 [5 favorites]

I had chronic post-nasal drip from my adenoids. (Apparently adenoids are supposed to shrink and disappear by the time you're an adult. Mine didn't. ) The only way I pinpointed the source was by going to an ENT and having him shove the camera up my face and say " Oh, wow your adenoids are huge!!" Followed by "that's gross!" In reference to all of the staphylococcus aureus growing up in them. He tried various rounds of antibiotics and nasal rinses before taking them out surgically. The rounds of antibiotics would make me feel better for a while, but it would slowly come back.
posted by Green Eyed Monster at 6:03 PM on August 17, 2018 [2 favorites]

Best answer: I am an emergency physician and you're overthinking this.

Here is what you need to do: choose a primary care physician you click with and return to them until the problem has been solved. Don't self-refer to pulmonologists or ENTs, or push for repeat CT scans of your chest, or for CTs of your sinuses, or of anything else -- I'm guessing from your other questions that you're relatively young? Don't take CTs lightly, as they'll have many decades to place you at higher risk for cancer. Let your PCP do their job and manage care, and let them draw on their expertise to decide when imaging and subspecialist input are needed.

Another round of antibiotics would probably be my next step here. With multiple weeks of upper respiratory congestion, sinus pressure and mild accompanying sore throat, I'd be thinking about a course of antibiotics for bacterial sinusitis as a first point of departure (though the vast majority of sinusitis is viral, and we way over-prescribe antibiotics for sinusitis, but that's a rant for another time). That would cover you for strep throat, too (which is pan-sensitive to all penicillins and related antibiotics), though it sounds very unlikely, and for most community-acquired pneumonias.

If you have a functioning immune system, your risk for really esoteric atypical infections is pretty low, though admittedly I think it's sensible to keep tropical causes in mind, and to push your PCP to think about those, given your residence in Costa Rica. Getting tested for the more common atypicals such as chlamidia (chlamydia pneumoniae, which is not the genital chlamydia you're thinking of), legionella and mycoplasma is also not unreasonable, though your current symptoms seem more upper respiratory than lower respiratory.

Get ye to a primary care doc, and keep following up until you and your PCP, working together, have the problem licked.
posted by killdevil at 6:49 PM on August 17, 2018 [8 favorites]

You do need a regular, PCP-type health provider. In the meantime, because budget is an issue, I think you should follow up with the pulmonologist who prescribed the two antibiotics and tell them what you've been experiencing since finishing those courses. They may be able to prescribe a different antibiotic without having to see you again/run more tests, and that new med might knock this out for good.
posted by Iris Gambol at 7:37 PM on August 17, 2018

Be aggressive about your dosing of Sudafed. Dry the source of the problem.
posted by quince at 10:59 PM on August 17, 2018

I have had a problem with post nasal drip for several years (and asked abput it on here at least once) and was finally able to resolve it with the advice of an ENT with mucinex expectorant -- withOUT any decongestant. No drying out, just loosening what's there. In his words, "not mucinex D-- remember, D means 'don't.'"

You have lots of good advice in this thread and it could be any one of the issues identified but if money is an issue, I would try the expectorant-only first. If you've been taking lots of meds, one or more of them may have a side effect (or intended effect) of trying out your nasal passages, resulting in a very irritating post nasal drip that almost feels like choking.

Dr told me that they learned during the AIDS epidemic that it's safe to take 2 x 1200mg per day. I take 1 x 1200mg and that works. 1 x 600mg isn't enough.
posted by janey47 at 12:23 AM on August 18, 2018 [2 favorites]

How long were you on the steroids for? I had a sinus blockage with bacterial infection for about a year once and a six day course of steroids was not effective, but a thirty day course was.

I would err toward reaching out to the same pulmonologist if possible to explain your symptoms have returned, as their course of treatment to date has been the most effective. They may end up referring you to an ENT.

In the meantime stock up on saline spray and try not to look up scary possibilities of what it could be. Good luck!
posted by donut_princess at 5:03 AM on August 18, 2018

I had an infection that wouldn’t go away and months later found out I was dangerously anemic. Has your doctor run basic blood tests?
posted by FencingGal at 7:24 AM on August 18, 2018

Response by poster: Thanks everyone... I haven't had general blood tests like for iron levels, in many years. There are several helpful ideas in the thread.

My biggest worry is the potential for pneumonia to return, or that it was never completely gone. From what I understand, walking pneumonia is scary because even when symptoms have mostly gone, the infection could be quietly progressing.

What I don't understand about pneumonia healing is this: The lungs get a buildup of fluid including bacteria and white blood cells. The patient takes antibiotics (and maybe steroids). Are those fluids supposed to all be coughed up so the lungs are clear? Or does the body somehow reabsorb the fluids from inside the lung and drain them without coughing, clearing the lung sacs?

Once I got on the antibiotics and steroids, my productive cough stopped. So this made me wonder how the infected lung fluids were supposed to come out, in the absence of coughing.

I will probably take most of the suggestions in the thread, including visiting a PCP. My concern is that a general practitioner ideally has to take enough of an interest, and spend enough time, to figure out the mystery of what's happening. I wish I could have a sort of Sherlock Holmes as my PCP, with virtuosic ability to look for clues, take it slow and not jump to false conclusions. In the worst-case scenario, a PCP takes 5-10 minutes to reach a snap decision and send you on your way. At least that's been my experience at times.
posted by TreeHugger at 10:39 AM on August 18, 2018 [1 favorite]

Is there any reason besides the absence of exhaustion to believe it isn’t mono? This is what it was like for me in the first couple months, the lingering nagging sinus drip cough thing.
posted by zinful at 11:39 AM on August 18, 2018

I'm blessed with a PCP who is a bird dog. She hunts until she gets it figured out and I know or have known 3 different people who had hard to diagnose conditions. She birddogged until my friends were diagnosed and on the mend. And so one time she asked me what I was taking for a cold I was complaining about and I said ibuprofen and she asked why wasn't I taking [cold medicine] and I said those just suppress symptoms rather than cure the problem, and she said take the meds, they treat the symptoms by solving the problem. So I think that goes to your question of whether there is gunk that has to come out and the drugs just stop that from happening vs whether the gunk is reabsorbed or otherwise not in need of coughing up.

My PCP also told me that pain medicine such as ibuprofen helps the pain of a sore throat which had never occurred to me before and I was in my late 30s when she told me, and had spent an awful lot of time as a youngster in agony from tonsillitis or strep. A good PCP can make all the difference.
posted by janey47 at 3:21 AM on August 19, 2018