What is the best course of treatment for a patient with a history of cancer presenting with cough and nasal congestion without fever?

Treatment Approach for Cough and Nasal Congestion in a Cancer Patient

This patient requires symptomatic treatment for an acute upper respiratory infection with oral pseudoephedrine for nasal congestion and dextromethorphan 60 mg for cough suppression, while addressing the concerning hypothermia (temperature 95°F) which demands immediate evaluation for sepsis or other serious complications. 1, 2, 3

Critical Initial Assessment

The hypothermia (95°F) is the most urgent finding and requires immediate attention. 1

• In immunocompromised cancer patients, hypothermia can indicate sepsis, particularly in the context of respiratory symptoms 1
• Despite the absence of fever, neutropenic patients with respiratory complaints can be afebrile and still have serious infections 1
• The patient's cancer history (skin and colorectal cancer) raises concern for potential immunosuppression, though the specific treatment status is not provided 1

Immediate actions needed:

• Obtain complete blood count to assess for neutropenia 1
• Consider blood cultures and chest radiograph if any concern for pneumonia exists 1
• Rewarm the patient and reassess vital signs 1

Management of Nasal Congestion

For the nasal congestion with yellow mucus, oral pseudoephedrine 60 mg every 4-6 hours is the appropriate first-line treatment. 3, 4

• Pseudoephedrine is FDA-approved to "temporarily relieve nasal congestion due to the common cold" 3
• Objective studies demonstrate pseudoephedrine 60 mg significantly reduces nasal airway resistance compared to placebo (p=0.006 after single dose, p<0.001 after multiple doses) 4
• Both single and multiple doses are safe and effective for nasal congestion associated with upper respiratory tract infections 4
• Topical nasal decongestants (oxymetazoline, xylometazoline) can be used for severe congestion but should be limited to 3-7 days maximum to avoid rhinitis medicamentosa 5, 6

Management of Cough

For cough suppression, dextromethorphan 60 mg is the preferred initial agent, as it is more effective than codeine with a much lower adverse effect profile. 2

Stepwise Cough Management Algorithm:

First-line: Dextromethorphan 60 mg 2

• The American College of Chest Physicians evidence shows dextromethorphan has "no greater efficacy disadvantage compared to codeine but has a much lower adverse side effect profile" 2
• The effective dose is 60 mg for maximum cough reflex suppression—most over-the-counter formulations contain subtherapeutic doses 2
• Meta-analysis demonstrates suppression of acute cough by dextromethorphan 2

Second-line: Simple linctus or glycerol-based cough syrups 1

• These demulcents (5 mL three to four times daily) provide symptomatic relief with minimal side effects 1
• Evidence from trials shows cough reduction with glycerol-based preparations 2

Third-line: Opioid derivatives (if non-opioid options fail) 1, 7

• Pholcodine or hydrocodone are preferred over codeine due to better side effect profiles 7, 2
• Codeine 30-60 mg four times daily is an alternative 1
• Morphine should be reserved for refractory cases 2

Fourth-line: Peripherally-acting antitussives 1

• Levodropropizine 75 mg three times daily, moguisteine 100-200 mg three times daily, or sodium cromoglycate 10 mg four times daily 1
• These are appropriate for opioid-resistant cough 1

Important Clinical Caveats

The absence of fever does not exclude serious infection in cancer patients. 1

• Neutropenic patients infected with respiratory viruses may be afebrile and lack classic systemic symptoms 1
• The hypothermia in this case is particularly concerning and may represent atypical sepsis presentation 1

Yellow nasal mucus does not automatically indicate bacterial sinusitis requiring antibiotics. 8

• Most upper respiratory infections are viral and self-limited 8
• Antibiotics should only be considered if symptoms persist beyond 10 days or worsen after initial improvement 8

Duration of treatment matters for nasal decongestants. 5, 6

• Oral pseudoephedrine can be used safely for the duration of cold symptoms 4
• Topical nasal decongestants must be limited to prevent rebound congestion 5, 6

Monitor for treatment response within 48-72 hours. 1

• If cough does not improve with initial pharmacologic approach, discontinue and try the next step in the algorithm 1
• Persistent or worsening symptoms warrant reassessment for complications like pneumonia or sinusitis 1, 8