What could be causing my chronic cough, weight loss, throat phlegm, basal congestion, and hoarseness while I'm breastfeeding?

Evaluation of Chronic Cough with Weight Loss, Throat Phlegm, Nasal Congestion, and Hoarseness in a Breastfeeding Patient

Your symptoms—chronic cough, weight loss, throat phlegm, nasal congestion, and hoarseness—most likely represent upper airway cough syndrome (UACS) from rhinosinusitis, possibly combined with gastroesophageal reflux disease (GERD), though tuberculosis must be urgently excluded given the presence of weight loss. 1

Immediate Priority: Rule Out Tuberculosis

Weight loss combined with chronic cough is a red flag that mandates immediate tuberculosis screening, regardless of breastfeeding status. 1, 2

• Obtain a chest X-ray immediately—this is the essential first step for anyone with chronic cough and systemic symptoms like weight loss 2
• Consider your geographic location and any travel history to tuberculosis-endemic areas 2
• Tuberculosis typically presents with afternoon fevers, night sweats, and weight loss lasting weeks to months 2
• A normal chest X-ray does not completely exclude tuberculosis, especially if you have any immune compromise 2

Most Likely Diagnoses After Excluding Tuberculosis

Upper Airway Cough Syndrome (UACS)

Your combination of throat phlegm (postnasal dripping sensation) and nasal congestion strongly suggests UACS as the primary cause. 1, 3

• UACS accounts for 92-100% of chronic cough cases in nonsmokers with normal chest X-rays, either alone or combined with other conditions 1
• Your nasal congestion and throat phlegm are classic rhinosinusitis-related symptoms with moderate sensitivity (72.9%) for UACS 4
• UACS can present as "silent" with cough being the only symptom, though you clearly have associated nasal and throat symptoms 1

Gastroesophageal Reflux Disease (GERD)

Your hoarseness raises concern for laryngopharyngeal reflux, which can occur without any heartburn or regurgitation in up to 75% of cases. 1, 3

• GERD is the second most common cause of chronic cough and chronic sore throat 1, 3
• Hoarseness was present in 100% of otolaryngology patients with laryngopharyngeal reflux but in 0% of gastroenterology patients with typical GERD 1, 5
• The absence of heartburn does not exclude GERD—up to 75% of patients with GERD-related chronic cough have "silent GERD" 1, 3
• Laryngoscopy may reveal red arytenoids and piled-up interarytenoid mucosa if reflux is causing your hoarseness 1, 3

Addressing the Breastfeeding and Weight Loss Connection

While breastfeeding can contribute to weight loss through increased caloric expenditure, it does not cause chronic cough, throat phlegm, nasal congestion, or hoarseness. 1

• The weight loss in your case is concerning because it occurs alongside respiratory symptoms, which is a pattern seen in tuberculosis and other serious conditions 1, 2
• Do not attribute your weight loss solely to breastfeeding when it accompanies chronic respiratory symptoms—this is a common pitfall that delays diagnosis 1, 2

Diagnostic Approach

Follow this algorithmic sequence:

1. Obtain chest X-ray immediately to exclude tuberculosis, lung cancer, or other structural abnormalities 1, 2

2. If chest X-ray is normal and tuberculosis is excluded:

   • Treat empirically for UACS with intranasal corticosteroids and antihistamines 1
   • Consider a trial of GERD therapy with proton pump inhibitors if hoarseness persists or if you have any reflux symptoms 1, 3
   • Refer to otolaryngology for laryngoscopy to evaluate for reflux laryngitis given your hoarseness 3, 5

3. Monitor response to treatment:

   • UACS typically responds within 1-2 weeks of appropriate therapy 1
   • GERD-related cough may take 2-3 months to respond to anti-reflux treatment 1

Critical Caveats

• Do not rely on cough character or timing to distinguish between causes—these features have no diagnostic value 1
• Do not assume you need heartburn to have GERD—silent GERD is the rule, not the exception, in chronic cough patients 1, 3
• Do not delay tuberculosis screening—weight loss with chronic cough warrants immediate investigation regardless of other symptoms 1, 2
• Multiple conditions often coexist—92-100% of chronic cough patients have one, two, or all three of UACS, asthma, and GERD 1