What is the cause of cough in a patient with bilateral hilar lymphadenopathy and a DeMeester (Gastroesophageal Reflux Disease severity) score of 9.8 on pH probe, indicating gastroesophageal reflux disease?

From the Guidelines

The cause of cough in a patient with bilateral hilar lymphadenopathy and a DeMeester score of 9.8 on pH probe is most likely sarcoidosis rather than gastroesophageal reflux disease (GERD). The normal DeMeester score (below 14.72) indicates that acid reflux is not contributing significantly to the cough symptoms 1. Bilateral hilar lymphadenopathy is a classic radiographic finding in sarcoidosis, which commonly presents with a persistent dry cough, shortness of breath, and fatigue. Sarcoidosis is a multisystem inflammatory disorder characterized by non-caseating granulomas that can affect the lungs and lymph nodes. Management typically includes monitoring for mild cases or corticosteroid therapy (starting with prednisone 20-40mg daily for 1-3 months, then gradually tapering) for symptomatic patients. Other medications like methotrexate (10-25mg weekly) or hydroxychloroquine may be used as steroid-sparing agents in chronic cases. Pulmonary function tests, serum ACE levels, and possibly bronchoscopy with biopsy would be appropriate next steps to confirm the diagnosis before initiating treatment. Supportive care with cough suppressants like codeine phosphate (10-20mg every 4-6 hours) or dextromethorphan may provide symptomatic relief while addressing the underlying condition. It's worth noting that the guidelines for managing chronic cough due to GERD suggest an empiric trial of medical antireflux therapy in patients who meet the clinical profile predicting that silent GERD is the likely cause of chronic cough or in patients with chronic cough who also have prominent upper GI symptoms consistent with GERD 1. However, in this case, the normal DeMeester score and the presence of bilateral hilar lymphadenopathy suggest that sarcoidosis is a more likely cause of the cough. Therefore, the most appropriate course of action would be to investigate and treat the patient for sarcoidosis, rather than pursuing further treatment for GERD.

From the Research

Possible Causes of Cough

• Bilateral hilar lymph nodes can be associated with various conditions, including amyloidosis, as seen in a case study where a 75-year-old male presented with bilateral hilar lymph node swelling and was diagnosed with amyloidosis using endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) 2.
• A high DeMeester score of 9.8 on pH probe suggests gastroesophageal reflux disease (GERD) as a possible cause of cough, as a DeMeester score above 4.2 is considered abnormal and indicative of GERD.
• The presence of GERD can lead to chronic cough, and the management of GERD is crucial in alleviating symptoms, including cough.

Management of GERD

• The medical treatment of GERD involves the use of anti-secretory therapy, such as proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) 3.
• For patients with persistent symptoms on PPIs, expert gastroenterologists recommend invasive therapy only in the presence of abnormal reflux burden, with or without hiatal hernia, or regurgitation with positive symptom-reflux association and a large hiatus hernia 4.
• Non-invasive pharmacologic or behavioral therapies, such as H2RAs, transient lower esophageal sphincter relaxation inhibitors, and neuromodulation/behavioral therapy, can be considered for patients with PPI nonresponsive symptoms 4, 5.

Relationship Between Bilateral Hilar Lymph Nodes and Cough

• The presence of bilateral hilar lymph nodes can be associated with various conditions, including sarcoidosis, lymphoma, and amyloidosis, which can cause cough as a symptom.
• However, the relationship between bilateral hilar lymph nodes and cough is not directly addressed in the provided studies, and further investigation is needed to determine the underlying cause of cough in this patient.