I have a cough that sounds like croup and I'm experiencing epistaxis (nosebleed) with blood mixed with mucus, what could be causing my symptoms?

Croup-Like Cough with Epistaxis: Evaluation and Management

Immediate Assessment and Action

You need urgent medical evaluation to rule out pertussis (whooping cough) and manage your nosebleed, as the combination of a croup-like cough with epistaxis suggests either severe paroxysmal coughing causing nasal bleeding or concurrent respiratory infection with trauma-induced bleeding. 1

First-Line Management for Your Nosebleed

• Sit upright with your head tilted slightly forward (not backward) to prevent blood from flowing into your airway or stomach 1, 2
• Apply firm, continuous pressure to the soft lower third of your nose for 10-15 minutes without checking if bleeding has stopped 1, 2, 3
• Breathe through your mouth and spit out blood rather than swallowing it 2
• If bleeding persists after 15 minutes, apply oxymetazoline (Afrin) or phenylephrine nasal spray to the bleeding nostril, then resume compression for another 5-10 minutes 2, 4

Understanding the Connection Between Your Symptoms

Pertussis causes severe paroxysmal coughing that can directly cause epistaxis through the extreme pressure generated during coughing episodes 1. The CDC guidelines specifically list epistaxis as a complication resulting from the pressure effects of severe coughing in pertussis patients 1.

• The characteristic "barking" or "whooping" cough you describe, especially if accompanied by paroxysms (successive coughs without inspiration), posttussive vomiting, or an inspiratory whoop sound, strongly suggests pertussis infection 1
• Pertussis has an insidious onset with catarrhal symptoms (nasal congestion, runny nose, mild cough) lasting 1-2 weeks before the paroxysmal stage develops 1
• The paroxysmal stage typically lasts 2-6 weeks with exhausting coughing episodes 1

Urgent Evaluation Needed

When to Seek Immediate Medical Care

You should see a doctor immediately because: 1

• You are coughing up blood mixed with mucus (hemoptysis with epistaxis) 1
• Your cough sounds like croup, which in adults raises concern for pertussis or other serious respiratory infection 1
• The combination of severe cough and epistaxis may indicate complications from forceful coughing 1

Diagnostic Considerations

Your physician should evaluate for:

• Pertussis infection: Diagnosed clinically when cough is accompanied by paroxysms, posttussive vomiting, and/or inspiratory whoop, unless another diagnosis is proven 1
• PCR testing for Bordetella pertussis if you are within the first 3 weeks of cough onset (when patients are most infectious) 1
• Other viral causes including parainfluenza virus (the most common cause of croup-like symptoms), respiratory syncytial virus, adenovirus, or Mycoplasma pneumoniae 1, 5
• Assessment for bacterial tracheitis, which can present with similar symptoms but is more severe 5, 6

Treatment Approach

If Pertussis is Confirmed or Suspected

• Oral macrolide antibiotics (azithromycin, clarithromycin, or erythromycin) are effective when administered early in the course of disease (ideally during the catarrhal stage or within the first 3 weeks of cough) 1
• Antibiotics reduce infectiousness and may shorten symptoms if given early, though they have minimal effect once the paroxysmal stage is established 1
• Patient isolation is critical as pertussis has a secondary attack rate exceeding 80% among susceptible persons 1

For Croup-Like Symptoms in Adults

• Unlike pediatric croup, adult croup-like presentations often represent pertussis or other bacterial infections requiring different management 1
• Humidification therapy has not been proven beneficial for viral croup 5
• Antibiotics have no role except for bacterial sinusitis or early pertussis infection 1

Ongoing Epistaxis Management

If your nosebleed continues despite initial compression:

• Seek emergency care if bleeding persists beyond 30 minutes of proper compression with vasoconstrictors 2, 3
• You may require anterior rhinoscopy to identify the bleeding site, followed by cauterization or nasal packing 1, 2, 4
• Use resorbable packing materials if packing is needed, especially if you take any blood thinners 2, 3

Prevention of Recurrent Nosebleeds

Once bleeding stops:

• Apply petroleum jelly or other moisturizing agents to your nasal mucosa twice daily 1, 2, 3
• Use saline nasal sprays regularly to maintain mucosal moisture 1, 2, 3
• Use a humidifier in dry environments 2, 3
• Avoid nose picking, vigorous nose-blowing, and nasal manipulation for at least 7-10 days 2

Critical Pitfalls to Avoid

• Do not tilt your head backward during a nosebleed, as this causes blood to flow into your airway and stomach 1, 2
• Do not stop compression prematurely to check if bleeding has stopped—this disrupts clot formation 2, 3
• Do not delay seeking medical evaluation for the cough, as pertussis is highly contagious and requires isolation and treatment 1
• Do not assume this is simple viral croup if you are an adult—croup-like symptoms in adults warrant investigation for pertussis or bacterial infection 1

Follow-Up Requirements

• Document outcome within 30 days of any epistaxis treatment 2
• If diagnosed with pertussis, close contacts require prophylactic antibiotics regardless of vaccination status 1
• Expect the cough to persist for weeks even with treatment, as the paroxysmal stage typically lasts 2-6 weeks 1
• A non-paroxysmal cough may continue for 2-6 weeks or longer during convalescence 1