What is the cause of a 4-week cough and costochondritis that improved with prednisone (a corticosteroid) but recurred after running out of the medication?

From the Guidelines

I strongly recommend restarting prednisone at 30-40mg daily for a short, finite period of time, as suggested by the American College of Chest Physicians (ACCP) evidence-based clinical practice guidelines 1, to manage the postinfectious cough and costochondritis. The patient's symptoms returning after stopping prednisone suggests that the underlying inflammation causing the costochondritis and cough hasn't fully resolved. While restarting the steroid will help control symptoms, it's essential to address the root cause. The guidelines suggest that for adult patients with postinfectious cough, a trial of inhaled ipratropium may be considered to attenuate the cough 1. Additionally, the guidelines recommend considering the use of inhaled corticosteroids in patients with postinfectious cough when the cough adversely affects the patient's quality of life and persists despite use of inhaled ipratropium 1. It's crucial to schedule an appointment with the doctor to discuss maintenance therapy options, such as non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen 400-600mg three times daily or naproxen 500mg twice daily, as suggested by the ACCP guidelines 1. The doctor may also consider prescribing an inhaled corticosteroid if the cough has an inflammatory or asthmatic component. During the acute phase, applying heat to the chest wall for 15-20 minutes several times daily and practicing gentle stretching exercises for the chest muscles can help alleviate symptoms. Avoiding strenuous activities that worsen chest pain is also essential. Prednisone works by suppressing inflammation but isn't suitable for long-term use due to side effects, which is why transitioning to other anti-inflammatory treatments is necessary for ongoing management. The ACCP guidelines emphasize the importance of a systematic approach to managing cough, including directing empiric treatment at the most common causes of cough, such as upper airway cough syndrome (UACS), asthma, and gastroesophageal reflux disease (GERD) 1. In patients with chronic cough, therapy should be given in sequential and additive steps because more than one cause of cough may be present 1. Smoking cessation is also crucial for patients who smoke, as it can help resolve cough symptoms 1. Ultimately, a comprehensive approach to managing the patient's symptoms, including medication, lifestyle modifications, and follow-up appointments, is necessary to ensure the best possible outcome.

From the FDA Drug Label

Metabolic clearance of corticosteroids is decreased in hypothyroid patients and increased in hyperthyroid patients. Corticosteroids, including prednisone tablets, suppress the immune system and increase the risk of infection with any pathogen, including viral, bacterial, fungal, protozoan, or helminthic pathogens Corticosteroids can: • Reduce resistance to new infections • Exacerbate existing infections • Increase the risk of disseminated infections • Increase the risk of reactivation or exacerbation of latent infections • Mask some signs of infection

The cause of a 4-week cough and costochondritis that improved with prednisone but recurred after running out of the medication is not directly stated in the provided drug label.

• The label discusses the immunosuppressive effects of prednisone and the potential for infection reactivation or exacerbation, but does not provide a clear link to the symptoms described.
• It also mentions that corticosteroid-associated infections can be mild but can be severe and at times fatal, but this information is not directly relevant to the specific symptoms. 2

From the Research

Possible Causes of Symptoms

• A 4-week cough and costochondritis that improved with prednisone but recurred after running out of the medication may be related to an inflammatory condition, such as costochondritis or Tietze syndrome, that responds to corticosteroids 3, 4.
• The improvement in symptoms with prednisone suggests that the condition may be related to inflammation, which is consistent with the use of corticosteroids to treat conditions such as costochondritis and Tietze syndrome 5, 4.

Role of Corticosteroids

• Corticosteroids, such as prednisone, are anti-inflammatory medications that can be effective in treating conditions such as costochondritis and Tietze syndrome 5, 4.
• The use of corticosteroids can provide relief from symptoms, but the underlying condition may still be present, which could explain the recurrence of symptoms after the medication was stopped 4, 6.

Potential Underlying Conditions

• Costochondritis is a common condition that can cause chest pain and tenderness, and it may be related to the symptoms described 3, 7.
• Tietze syndrome is a rare form of chest wall costochondritis that can cause significant chest pain and decline in ability of daily activities, and it may be related to the symptoms described 4.
• Pulmonary sarcoidosis is a condition that can cause cough and chest pain, and it may be related to the symptoms described, although it is less likely given the response to prednisone 6.