Expert: Marc Rubin, RPh Asthma Educator - 7/14/2011

Question
QUESTION: Hi Dr Rubin,

Not sure if asthma is appropriate specialty for my questions, however I believe you may be able to help.

I live in a small town, and I have dogs that according to recent allergy testing I am not allergic to. I have been on allergy meds, inhalers and now dexilant for potential reflux.

I am 50 years old and work in a dusty office, very dust house, and have many allergies, ie: dust, mold, cats, trees, pollen, grasses, etc. Live in an old house with a moldy wet basement.

I developed a chronic cough in late december. I attributed it to the cut evergreen christmas tree that I know I am allergic to. cough increased gradually and lasted atleast 10 weeks. Was seen by my family dr. and rx'd : cough med with codeine, oral cough meds, allergy meds, inhalers, nebulizer txs., oral steroids. Had negative chest x-ray. Out of work for 6 days as cough was severe. No URI symptmoms, whatsoever. No post nasal drip, fever, etc. Ultimately referred to asthma and allergy specialist to rule out RAD. Family Dr aware from old allergy testing that I had multiple allergies, and cough was unresolved with all of the above meds.

Allergist did allergy testing, and found same results with the exception of allergy to my dogs. She checked my breathin (in office) with machine you blow into and then checked again following inhaler , as did my family Dr. Breathing caused increased cough, but inhaler and neb didn't seem to make any real difference. Again, left with allergy meds (oral and nasal sprays), eye drops, inhalers (inc rescue inhaler), PPI for reflux, and so on. Lots and Lots of medicine. Cough ceased about 10 wks later, and returned again within about 3 wks.

Allergist discussed reflux as she is fairly certain that this is the problem. Although, I wasn't using the PPI as directed, and cough went away and came back. Again, back on ppi and inhalers. Cough D/C'd for about 2 wks and now back with a decreased severity for another 10 or so days at this point. Talking, eating , and odors, seem to cause increased coughing (as well as a dusty environment. Off inhalers, and all allergy meds as symptoms with lungs and rhinits, allrgic conjunctivitis gone.

Now referred to ENT to rule out that hoarseness was not caused by vocal cord nodules related to cough? Ent said nothing wrong with vocal cords, etc. no nasal drip or related issues? As I have no other symptoms than cough, (ie: heartburn, breathing issues etc )he did state that this may be silent reflux if my Allergist ruled out asthma ? ,which I'm not sure of. Could this be cough variant asthma? I have been using the new PPI for about 5-6 wks now, and watching my diet most of time. ENT was very vague and mentioned usually when asthma has been ruled out the patient is referred to a pulmonologist. I asked about a gastroenterologist, which he remarked remarked "that too". He told me that I should probably keep taking the PPI for another month and then follow up with allergist.

Sorry so wordy, but really cannot continue for another month with this quality of life, and no real diagnosis. Where to next? What do you think (read up), about silent reflux vs. cough variant asthma ? Or something else entirely. I do not smoke, and never have.

Also, another symptom, which Dr did note as a dx on my receipt is wheezing. Doesn't wheezing traditionally sound like a whistle? I do not have a whistle, however frequently have a honking sound and mild difficulty catching my breat between inahiling and exhaling while coughing?

Please give me any advice at all! It is greatly appreciated ! Sorry to be so wordy, but felt the need to be thorough in describing this horribly annoying problem. Can't afford to invest much more money with this cough. I have paid well over $1000, with copays, deductibles, medications etc.

Thanks again so much for your time.
-Sherri

ANSWER: Hi Sherri,

First of all, please do not apologize for the length of your question! I wish all my writers gave as great a background as you have. And actually, I will need a bit more.

I believe a major cause is the moldy basement. I have a patient who had her home checked, and they discovered the the rafters and beams in her roof were full of mold. Fortunately, they were able to have the entire roof structure replaced. Shortly thereafter, almost all of her asthma meds were eliminated. This area would be my focal point to clear up.

Now, what I need in addition are these additional items:

Ethnicity (caucasian, asian, hispanic, afro-american, etc.) The reason for this is some groups do not react equally to some of the treatments.

Height and weight

Did the doctor give you any blood testing results on a printed sheet? If so, include that also.

Actual drug list and time frames. If you go to your pharmacy, request a printout of all your medications. Then list them for me with a bit of time frame reference, especially to your lung testing. And I need to know ALL of your meds, including over the counter, since some meds can cause or worsen this problem. If you have taken some meds that you found didn't do anything, include those also, and note that they didn't work.

Hopefully from this I'll be able to provide you with direction to get this under control.

Sincerely,

Marc

---------- FOLLOW-UP ----------

QUESTION: Hi Marc,
Thanks for such a quick response.  To answer some of your questions : I am a caucasion woman , 5'3" tall, and weight about 150 lbs (unfortunately). I have had no blood tests since cough began in January. Prior to that everything normal. The only breathing test that I had was spirometry? in office with allergist and whatever the the test is that you breathe into a tube and try to raise a ball , at my pcp's office. My breathing was poor at pcp,s when this all began in January, but neb txs and inhalers didn't seem to effect this. I don't know the result of the spirometry but inhalers (think ventolin) didn't seem to make a big difference. Allergist did mention that she didn't give it much time to work. Yes my old house is very moldy, yet I have lived there for 23 yrs. without significant problem I am allergic to mold and the allergist feels that we should try to resolve the problem. We cannot afford this, as is monumentally expensive. The house is 107 yrs old and has a wet stone basement.

In mid -January I was rx'd cough med with codeine, tessalon pearls , medrol dose pak, Mussinex (OTC) , allegra, and 2 nasal sprays ( 1 steroid), ( 1 antihistamine). Ventolin (spelling?) rescue inhaler, and another (longer acting steroid inhaler). This was per my pcp.  I beleive I was referred to the allergist /asthma specialist in early February to rule out RAD , related to my allergies. I had allergy testing about 10 yrs ago or so, and did inform my pcp of the results. All of this time I had no post nasal drip or other symptoms than the cough. As I mentioned chest x-ray negative.

Allergist kept me on basically same meds., except beleives I have reflux, so added omeprazole. She also changed the steroid inhaler to Advair at my request. I had used Advair years ago for cough ,and was easier to use. Rescue inhaler remained same. She did the allergy testing which showed same results mentioned in previous. Did (spirometry), not sure that is the actual test she did. I breathed into tube, and computer measured my breathing. Again don't know actual reading, and she wasn't sure if inhalers helped. No neb this time. She felt that I definitely have reflux, possibly combine with asthma. She now does not feel I have asthma , but believes I have reflux. This is her dx.

I must admit that I did take all of the meds as prescribed with the exception of the omeprazole. I kept forgetting, to take 1/2 hr before mail. Some days didn't take, etc. Kept coughing for another couple of months. Cough then completely subsided. Taken off all of the meds inc inhalers and omeprazole at the same time (except the allergy meds). This was probably around mid April of so. Off allergy meds in early June, season change with no symtpms except itchy water eyes. I thought allergic conjuctivitis, Dr thought dry eyes and antihistamines would cause more issues. Had no cough this time for a couple of weeks, and then back full force. Called Dr she asked me to start inhalers again and omeprazole. No help, back again doesn't think its asthma. Changed reflux med to Dexilant a new drug. Can be fast acting or take 3-6 mths !!!! Been taking for nearly 6 wks and following the diet, with no relief.

Went to ENT who said all is well with vocal cords, larynx etc etc. He didn't mention acid regurg. Although said I should stay on Dexilant for another mth (this visit was this past Monday, 4 days ago). I should then follow up with allergist with the result. He felt that if the allergist ruled out asthma, I should be referred to pulmonary. I asked about Gastro for reflux and he agreed with that option as well. I contacted my pcp. Now only taking Dexilant and occaisonal allergy eye drops. PCP thinks I should try Gastro before pulmonary specialist? but is not absolutely sure.

My cough came back the very day I returned home from my one week vacation on a beach with no mold and a dry environment. However I also returned to my job which does require alot of phone use and talking really exasperates this situation.  Odors, dust etc also make me cough. My house is very dusty as weel. It has been dry for a mth or so, In fact semi-drought (eastern US). However prior to this, we had alot, alot of rain. ?????

Allergist now wants me to see speech therapist as she believes I have acid on my vocal cords, and no wheezing or breathing issues? ENT saw no acid, and pcp doesn't understand the reasoning behind this. I think it is rather silly. I need a dx and appropriate tx, as I'm worn down, getting headaches from hacking etc. etc. I take occaisonal ibuprofen for headaches and neck pain. I had cervical spine surgery about 1 yr ago. Didn't cause cough though, (anterior approach). Didn't cough until 6 mths after surgery. Silent Reflux ??? Cough variant asthma? allergies (mold)? other problems???? Who to next? Possibly Gastro? Pulmonary ? (probably not) . I can't even think straight. Could really use another opinion !!! Again wordy, wordy, wordy. Thanks,I hope I answered all of your questions (some several times I'm sure). Appreciate any advice you might give. - Sherri

Answer
Hi Sherri,

Acid on the vocal cords???...I have to agree with your PCP. There is a condition called Vocal Cord Dysfunction (VCD) which is related to stress. It is easy to detect by visually scoping the vocal cords with a bronchoscope. It can also be seen on s spirometry test, as well as by sonic evaluation with a microphone hooked up to an oscilloscope.

Are you on any blood pressure medication? A very commonly used class for this treatment are ACE inhibitors. They frequently have the side effect of this type of coughing.

Going back on some issues:
1) Grasses pollinate in early summer: probable explanation for eye issues, although I'd also expect some nasal problems also. If eyes only, I'd talk to the doctor about Lotemax.If both eyes and nose, then a nasal steroid called Veramyst (used ONLY in the nose) reduces and frequently eliminates both symptoms. A nerve from the nose merges in the brain with a nerve from the eyes. Due to that commonality, by reducing the nerve inflammation, both symptoms subside.

2) When you are having a flareup, I'd want to get a) a complete blood count(CBC) with differential. Certain white blood cells dramatically elevate with allergic symptoms. I want to know those. b) an IgE level...this is another indicator of the bodies immune response, and 3) a sputum eosinophil test, to see of there is the possibility of allergic esophagitis.

3) After your symptom free vacation, and the return to your moldy home and symptoms, I really believe that that is the central issue taking place. Due to your health issues, it may be possible that either your insurance company may pick up at least part of the tab for cleaning, or also check with your local health department if you can get govt. help on this.

If the numbers all come back normal. My next destination would be a pulmonologist.

I'm leaving in 5 hours for vacation, and will not be back until Aug 7th. Hopefully you will be able to get those labs back to me by then.

Talk to you soon!

Marc