What is the initial workup for a patient presenting with axillary (arm pit) pain and cough?

Initial Workup for Axillary Pain and Cough

For a patient presenting with axillary pain and cough, the initial workup should include a chest radiograph to evaluate for underlying pulmonary pathology, followed by targeted investigations based on clinical findings. 1, 2

Initial Diagnostic Steps

• Obtain a chest radiograph as the first-line imaging test to evaluate for pneumonia, malignancy, or other structural abnormalities 1, 2
• Assess for red flags including hemoptysis, smoking history (especially in patients >45 years with new cough), prominent dyspnea, hoarseness, systemic symptoms (fever, weight loss), and trouble swallowing 2
• Evaluate the characteristics of cough (acute, subacute, or chronic) to guide further diagnostic approach 1, 3
• Consider the possibility of malignancy affecting the upper thoracic nerve roots, especially if axillary pain is severe or progressive 4

Further Evaluation Based on Initial Findings

If Chest Radiograph is Normal or Nonspecific:

• For patients with normal chest radiograph but persistent symptoms, consider CT chest with IV contrast, especially if there is high clinical suspicion for underlying pathology 1
• CT chest with IV contrast has shown positive predictive value of 90% when used in patients with suspected underlying pulmonary disease 2
• Consider the most common causes of cough including:
  • Upper airway cough syndrome (UACS)/post-nasal drip 1
  • Asthma or bronchial hyperresponsiveness 1
  • Gastroesophageal reflux disease (GERD) 2

If Chest Radiograph Shows Abnormalities:

• For suspected pneumonia or parapneumonic effusion, CT chest with IV contrast is recommended (acquiring the CT scan 60 seconds after IV contrast bolus optimizes visualization of pleural abnormalities) 1
• If malignancy is suspected, particularly with axillary lymphadenopathy, consider CT chest with IV contrast to better evaluate for primary lung malignancy or metastatic disease 1, 5

Special Considerations for Axillary Pain

• Evaluate for axillary lymphadenopathy with physical examination and consider ultrasound if lymph nodes are palpable 5
• Consider the possibility of axillary web syndrome, especially in patients with history of breast cancer surgery 6
• Evaluate for upper thoracic radiculopathy, particularly if pain is severe or progressive, as this may indicate malignant pathology affecting the upper thoracic nerve roots 4

When to Consider Additional Testing

• If cough persists after consideration of common causes, perform a chest CT scan and, if necessary, bronchoscopic evaluation 1
• Consider sputum culture, complete blood count, and inflammatory markers such as CRP if symptoms worsen or fail to improve with initial management 1
• For patients with suspected malignancy, consider excisional biopsy of enlarged axillary lymph nodes 5

Common Pitfalls to Avoid

• Don't rely solely on chest radiography to exclude all pathologies, as studies show up to 34% of CT-proven bronchiectasis cases had unremarkable chest radiographs 2
• Avoid empiric antibiotic therapy for cough unless there is clear evidence of bacterial infection 1
• Don't dismiss axillary pain as musculoskeletal without considering potential serious underlying causes, particularly in the presence of systemic symptoms 4, 5

Remember that the combination of axillary pain and cough raises concern for potential serious pathology, including malignancy affecting the upper thoracic nerve roots or lymphatic spread of disease, and warrants thorough evaluation 4, 5.