After 5 years, my cough disappeared--did pulmonologist fail me?

July 23, 2022 11:47 AM

YANMD - I have been battling a chronic, productive cough for 4-5 years. I am an otherwise healthy 48-year old man with well-controlled asthma and a severe allergy to both dogs and cats (that I've learned to live with). We have 3 cats in my home. After many pulmonology visits, CT scans, X-rays, etc., the general consensus was that it was the cats causing the cough. A few months ago, my cough disappeared after a short course of antibiotics. How?

After a chest x-ray I was diagnosed with a light case of pneumonia about 6 weeks ago in 5 minutes by an urgent care physician (!!!). I had not taken antibiotics in at least 10 years. Within two days of starting, my cough vanished and has not come back.

Is it possible that I've had walking pneumonia for 4+ years? How does a very well respected pulmonologist who I saw half a dozen times over these years miss a pneumonia and fail to prescribe antibiotics? I visited with the urgent care doc for 5 minutes.

I'm curious for my own knowledge more than anything, and while I have asked the pulmonologist I don't expect an answer.

Is there a rational justification for why the pulmonologist wouldn't have prescribed antibiotics, or is there some other explanation?

posted by eggman to Health & Fitness (10 answers total)

Did you get checked for mycobacterium avium complex? The treatment for it is a long-term course of antibiotics, perhaps what you took has started helping.
posted by nanook at 12:24 PM on July 23, 2022 [2 favorites]

Best answer: I am a doctor, but not your doctor, and this is not medical advice.

There are types of lung infections that you can have for a long time (MAC is one example mentioned above), but as an otherwise healthy 48-year old with presumably normal CT scans, the likelihood that you had untreated MAC--or any other infectious pneumonia--is pretty low.

If I had to guess, I think the most likely explanation for this series of events is that the antibiotics you were prescribed are one of the antibiotics that have anti-inflammatory properties in addition to their anti-bacterial properties. Azithromycin is the canonical example in this class and is also a particular favorite of urgent care doctors. If there is chronic inflammation playing a role in your chronic cough, such an antibiotic could easily relieve the symptoms of your cough without you ever having had any kind of infection.

Now you might wonder, if antibiotics can fight inflammation like this, and so many chronic coughs are due to inflammation, why don't we prescribe antibiotics to everyone? They've been studied in many populations and found to have long term benefit in only a small subset of patients who meet specific criteria. The rest of folks either don't benefit or their benefit is outweighed by other problems associated with longterm antibiotic use (e.g. GI upset).

I hope your relief is long lasting, but I would not be surprised if your cough eventually comes back.
posted by telegraph at 12:53 PM on July 23, 2022 [25 favorites]

I have asthma, in the form of a chronic dry cough in cold weather and/or periods of inflammation, typically kick-started by a cold. It took a doctor who actually listened to me to diagnose it properly, the urgent care PA refused to proscribe a steroid inhaler even though I had broken blood vessels in my eye from coughing. I always have a steroid inhaler on hand, just a simple non-controlled-dose version. It brings the cough under control in 7 -10 days or so. I get a lot of short-term relief from menthol cough drops which do reduce airway inflammation.

Covid isolating and masking has been a huge help; haven't had a flare-up in ages.
posted by theora55 at 1:51 PM on July 23, 2022

My son's infant eczema was almost entirely "cured" by hardcore antibiotics that he had to take for a persistent ear infection. He had a handful of flares after that, but it went from "this could be a chronic, lifelong issue" to a very manageable, occasional thing. Sometimes your system just needs space to heal and an antibiotic can give you that space. But other times they can make things worse! It's not a risk-free thing to try.
posted by potrzebie at 5:06 PM on July 23, 2022

After many pulmonology visits, CT scans, X-rays,

After a chest x-ray I was diagnosed with

diagnosed from that, and just from that? then it should be pretty easy to find out whether the other doctor missed what this doctor found. get copies of your old & new chest x-rays and have someone (not your pulmonologist) compare & tell you if the same signs are visible on both.
posted by queenofbithynia at 5:37 PM on July 23, 2022 [1 favorite]

I’ve been coughing for 8 years.

In my case the best theory is that it’s neuropathic, that getting whooping cough damaged my Vagus nerve and now I cough to protect my airway, which perceives everything as a threat. I’ve had times of near remission and times when it’s godawful. I’m happy to talk about any of my experiences, treatments, etc .

I also have a 30 page personal essay about all that, but I won’t force it on anyone. 🤣
posted by mermaidcafe at 7:45 PM on July 23, 2022 [4 favorites]

I think the most likely explanation for this series of events is that the antibiotics you were prescribed are one of the antibiotics that have anti-inflammatory properties in addition to their anti-bacterial properties. Azithromycin is the canonical example in this class and is also a particular favorite of urgent care doctors

I am prescribed a low dose of Azithromycin 3x per week (so I only take it Monday/Wednesday/Friday). This is a long term prescription. My pulmonologist prescribed it for my treatment resistant asthma, with the same rationale given above - that it has anti inflammatory properties.

If your cough does come back once you finish the course of antibiotics, this might be something to explore with your pulmonologist. I guess there is some research supporting its use this way in certain populations with asthma.
posted by litera scripta manet at 4:16 AM on July 24, 2022 [2 favorites]

Best answer: To build on telegraph's response, there is a stunning suite of infectious and non-infectious inflammatory responses that are (very) poorly understood. The immune system is extremely weird in many respects, and it has dependencies/contingencies that respond to every other system in your body. Tilting the inflammatory state in one eyetem can have unpredictable cascading effects in another. "Idiopathic" is a common word in my field (epidemiology, immunology), and even though correlation =/= causation sometimes it's hard to ignore a correlation like this and still come up with nothing more than a well-educated shrug. Your pulmonologist has been focused on predictable, explicable cause-and-effect relationships. It's absolutely worth bringing up this experience from your round of antibiotics with them, and yes it's possible that they missed a very basic diagnosis, but without more information I'd offer that an idiopathic response to the antibiotic is what's at play.

Good luck and many cough-free days upon you!
posted by late afternoon dreaming hotel at 2:48 AM on July 25, 2022 [1 favorite]

Yes! There is research to show that bronchoscopy (a procedure you didn't list) can help identify underlying causes of refractory asthma, including chronic cough caused by infection. Definitely worth looking into so if it is a bacterial infection they can properly diagnose it and the course of antibiotics.
posted by LKWorking at 3:29 PM on July 25, 2022

re: Cats - I have a cat allergy, but it's markedely improved over the last decade. Also, when one of my cats (no longer with us) was sick, they stopped grooming, and my allergy got much better (probably because I'm allergic to something in cat saliva). Have you been with the same cats for years? Any of them recently sick?
posted by soylent00FF00 at 3:44 PM on July 26, 2022