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Case records of the Massachusetts General Hospital. Case 6-2015. A 16-year-old boy with coughing spells.

Dr. Mark A. Goldstein (Pediatrics): A 16-year-old boy was seen in the adolescent medicine outpatient clinic of this hospital in late spring because of coughing spells. The patient had been well until approximately 3 weeks before the current presentation, when cough and nasal congestion developed and persisted, without fever or chills. He took fexofenadine hydrochloride, without improvement. Three days before the current presentation, he awoke at night with a severe coughing spell, with associated post-tussive emesis and trouble breathing. His parents took him to the emergency department of another hospital. On examination, he appeared to be in no distress; the temperature was 37.0°C, the blood pressure 152/87 mm Hg, the pulse 107 beats per minute, the respiratory rate 18 breaths per minute, and the oxygen saturation 100% while he was breathing ambient air. The mucosa of the posterior oropharynx had a cobblestone appearance and the uvula was midline; there was no tonsillar edema or exudate. Nasal congestion, boggy nasal mucosa, and serous effusions behind both tympanic membranes were evident. The lungs were clear on auscultation, and the remainder of the examination was normal. A diagnosis of allergic rhinitis with the upper-airway cough syndrome (postnasal drip) was made, and fluticasone propionate nasal spray and benzonatate (200 mg three times daily) were prescribed. The next day, the patient continued to cough but was able to attend school. That night, he awoke from sleep with an episode of severe coughing that lasted approximately 10 minutes and was associated with two episodes of vomiting. He returned to the emergency department of the other hospital. He reported no chest pain, fevers, night sweats, or weight loss. On examination, he appeared to be well and was not coughing; the temperature was 36.8°C, the blood pressure 151/87 mm Hg, the pulse 93 beats per minute, the respiratory rate 18 breaths per minute, and the oxygen saturation 97% while he was breathing ambient air. Mild nasal congestion and erythema of the posterior pharynx were present, and the remainder of the examination was normal. A chest radiograph was reportedly normal. A presumptive diagnosis of bronchospasm was made. A dose of dexamethasone was administered for treatment of possible croup, and an albuterol inhaler was prescribed. The patient was advised to follow up with his pediatrician. From the Department of Medicine, Bos‐ ton Children’s Hospital (M.R.W.), the De‐ partment of Pediatrics, Massachusetts General Hospital (K.S.B.), the William A. Hinton State Laboratory Institute, Mas‐ sachusetts Department of Public Health (A.D.), and the Departments of Pediat‐ rics (M.R.W., K.S.B.) and Population Medicine (A.D.), Harvard Medical School — all in Boston.