In a 37‑year‑old man with hypertension on telmisartan who presents with two weeks of watery rhinorrhea, a frontal headache worse in the morning, and a new productive whitish‑yellow cough without dyspnea and a normal exam, what is the most likely diagnosis and what are the next steps in management?

Most Likely Diagnosis: Post-Viral Upper Airway Cough Syndrome (UACS) with Possible Acute Bacterial Rhinosinusitis

This 37-year-old man most likely has post-viral upper airway cough syndrome (UACS, formerly postnasal drip syndrome) that has progressed to acute bacterial rhinosinusitis, given the 2-week duration of symptoms, frontal headache worse in the morning, and development of productive cough with purulent (whitish-yellow) sputum. 1

Clinical Reasoning

Why UACS with Secondary Bacterial Rhinosinusitis is Most Likely:

• Timeline supports bacterial superinfection: Initial watery rhinorrhea for 2 weeks followed by purulent discharge and productive cough indicates progression from viral to bacterial infection 1
• Frontal headache worse in morning: This pattern is characteristic of sinusitis due to overnight mucus accumulation and sinus pressure 1
• Productive cough with whitish-yellow sputum: The nasal drainage has become cellular and cloudy due to organisms, white blood cells, and desquamated epithelium, consistent with bacterial infection 1
• Duration >10 days without improvement: Viral rhinitis typically resolves within 7-10 days; persistence beyond this suggests bacterial superinfection (occurs in <2% of viral cases) 1

Key Differentiating Features:

• Not simple viral URI: Symptoms have persisted 2 weeks without resolution 1, 2
• Not allergic rhinitis: Watery discharge changed to purulent; no mention of itching, sneezing, or seasonal/exposure patterns typical of allergic rhinitis 1
• Not acute bronchitis alone: The productive cough developed secondary to nasal symptoms, suggesting postnasal drainage rather than primary bronchial infection 1

Important Caveat About Hypertension Medication

The patient's telmisartan is NOT causing these symptoms. Telmisartan does not cause cough, unlike ACE inhibitors (which cause persistent dry cough in up to 10-20% of patients). 3, 4 This is a key advantage of angiotensin receptor blockers over ACE inhibitors. 3

Next Steps in Management

Immediate Treatment Approach:

1. First-Generation Antihistamine/Decongestant Combination 1

• Prescribe dexbrompheniramine 6 mg + pseudoephedrine 120 mg sustained-release, twice daily
• This combination has proven efficacy for UACS in controlled studies 1
• The anticholinergic effect of first-generation antihistamines is crucial for non-histamine-mediated rhinitis 1
• Improvement should occur within days to 2 weeks 1

Alternative if contraindications exist (glaucoma, benign prostatic hypertrophy): 1

• Ipratropium bromide nasal spray

2. Consider Antibiotic Therapy 1

• Indications for antibiotics: Symptoms >10 days without improvement, purulent discharge, facial pain/pressure 1
• First-line choice: Amoxicillin-clavulanate (covers S. pneumoniae, H. influenzae, M. catarrhalis) 1
• Duration: 5-10 days 1

3. Symptomatic Management 2

• Ibuprofen 400-600 mg every 6-8 hours for headache 2
• Saline nasal irrigation 2-3 times daily (no rebound effect) 2
• If using topical decongestant, limit to 3-5 days maximum to avoid rhinitis medicamentosa 2

Critical Red Flags Requiring Immediate Reassessment:

Return immediately if: 2

• Symptoms persist >10 days without improvement or worsen after initial improvement
• High fever >39°C with severe unilateral facial pain
• Severe headache with neck stiffness, vision changes, or mental status changes
• Development of periorbital edema or erythema (suggests orbital complications)

Diagnostic Workup if Symptoms Persist:

If no improvement after 2 weeks of treatment: 1

• Chest radiograph to exclude pneumonia or other pulmonary pathology
• Spirometry to rule out underlying asthma or COPD (especially given recurrent morning cough) 1
• Consider referral to ENT for nasal endoscopy if structural abnormalities suspected

Common Pitfalls to Avoid:

1. Don't use newer-generation antihistamines (loratadine, terfenadine): These have been shown ineffective for post-viral UACS because they lack the anticholinergic properties needed 1

2. Don't assume this is simple allergic rhinitis: The progression from watery to purulent discharge and lack of typical allergic symptoms (itching, sneezing) argues against this 1

3. Don't discontinue telmisartan: This medication is not causing the cough and provides important cardiovascular protection 3, 4

4. Don't miss underlying asthma: If patient has recurrent episodes or persistent cough despite treatment, consider therapeutic trial of bronchodilators and spirometry 1