Allergies only or asthma/cough variant asthma also?

Patient

Q: My PCP said I only have allergy/allergic rhinitis, but she said I have to take Flonase, Singulair for long-term and keep Albuterol inhaler handy. Could it be asthma/cough variant asthma also? How to (or when should I) follow up my PCP and ENT?

**********

Full story:

Family history: My sister & dad have rhinitis. My mom has chronic cough and her PCP said it’s allergic (don't have detail check-up). I had strong allergic reaction to Erythromycin (whole body & face swollen & covered by hives/rash) when I was a kid

Since 2010, I started feeling nasal congested and post-nasal drip at night (bedtime & early morning) and okay in daytime. Occasionally took Claritin because of tickle in throat but nothing serious. Normal daily life & sleeping is fine.

Things started changing in 2013-2014.

Oct 2013 when I was 30 (female), me & my husband moved from Culver City CA (Los Angeles) to Carson CA (South Bay).

Jan 2014, I had flu for 2 weeks (101F fever + cold symptoms).

In Feb, my PCP started prescribing Flonase (50 mcg 2 sprays per day) as I had really bad nasal/sinus congestion, tickle in throat & cough did not go away.

In Apr, hacking cough still, started feeling chest tight & had disturbed sleep on and off for 2 weeks. PCP prescribed Albuterol and gave me relief. I did chest x-ray, lung function test (carbon monoxide diffusing capacity + spirometry before & after bronchodilator), blood test and nothing is abnormal. Cough is on and off.

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Blood Test Results:

WHITE BLOOD CELL DIFFERENTIAL

Component Standard Range **My Value**
NEUTROPHILS %, AUTOMATED COUNT 42.0 - 75.0 % **67.7**
LYMPHOCYTES %, AUTOMATED COUNT 20.0 - 51.0 % **22.5**
MONOS %, AUTO 1.0 - 12.0 % **8.0**
EOSINOPHILS %, AUTOMATED COUNT 0.0 - 10.0 % **1.1**
BASOPHILS %, AUTOMATED COUNT 0.0 - 1.0 % **0.7**
NEUTROPHILS, ABSOLUTE, AUTOMATED COUNT 1.8 - 7.7 x1000/mcL **3.4**
LYMPHOCYTES, AUTOMATED COUNT 1.2 - 3.4 x1000/mcL **1.1**
MONOCYTES, AUTOMATED COUNT 0.1 - 1.0 x1000/mcL **0.4**
EOSINOPHILS, AUTOMATED COUNT 0.0 - 0.7 x1000/mcL **0.1**
BASOPHILS, AUTOMATED COUNT 0.0 - 0.2 x1000/mcL **0.0**

CBC (COMPLETE BLOOD COUNT) WITH DIFFERENTIAL

Component Standard Range My Value
WBC'S AUTO 4.0 - 11.0 x1000/mcL **4.9**
RBC, AUTO 4.20 - 5.40 Mill/mcL **4.30**
HGB 12.0 - 16.0 g/dL **14.4**
HCT, AUTO 37.0 - 47.0 % **40.4**
MCV 81.0 - 99.0 fL **93.8**
MCH 27.0 - 35.0 pg/cell **33.4**
MCHC 32.0 - 37.0 g/dL **35.6**
RDW, BLOOD 11.5 - 14.5 % **12.2**
PLATELETS, AUTOMATED COUNT 130 - 400 x1000/mcL **210**
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In Jun, had really bad coughing fit at night & couldn’t sleep (used 6-8 puffs per week) and I had to visit urgent care next morning. Urgent care doc suspected I have asthma/cough variant asthma so she gave me a trial of Singulair (10 mcg for 3-month) + spacer. After that, started feel less cough, chest tight (now use 2-4 puffs per month) and tickle in throat, but still feel a bit congested.

In Aug, my PCP referred me to ENT (I am on HMO) and suggested to add Astelin for treating me persistent rhinitis. I did an allergy blood test for 13 kinds of environmental allergen but it’s negative. (At that time, I was taking Flonase, Singulair, and occasionally Claritin)

Later, I was asked by a nurse to get not only the flu shot and also a pneumococcal shot. I did get those shots when I went for another visit.

**********

I did ask my PCP if I am having asthma. She said it’s only an allergy/ allergic rhinitis.

However, she said I need to keep taking/refilling Flonase & Singulair for long-term, and keep my Albuterol handy. My PCP said I can use the inhaler if I cough a lot at night, feeling short of breathe or wheezing (not sure if I have wheezed before...)

How should I follow up with my PCP &/or ENT? I feel a bit better when the weather is warm/hot, but easy to start coughing when it’s cold, temp change, dusty room or laughing hard.

Current status:
Symptoms (tickle in throat, cough, chest tight) show improvements while I am taking Singulair (now is the 4th month). Still using Flonase (PCP said reduce dose from 2 sprays per nostril daily to 1 spray per nostril daily) . Need Albuterol 2-4 puffs per month (as need). Consistently feel "weird"/mild pressure in my throat/chest but less coughing fit and flare-up.

Symptoms:  - Post-nasal drip + nasal congestion close to bedtime and wake up in morning
- Tickle in throat
- Dry cough close to bedtime and wake up in morning
- Occasionally coughing fit/flare-up + chest tight + short of breathe (not often)
Doctor

A:   Thank your your question and details provided.

I note that asthma testing was normal and I note a chest xray was done at that time to rule out other possibilities of the cough.

The difference between allergic rhinitis and an environmentally triggered cough variant asthma is difficult to distinguish and often it is better to treat based on symptoms as opposed to testing. If the conditions are mild, testing can often be normal.

Both conditions suggest inflammation of the airways triggering an inflammatory response. We now realize that the nasal and lung airways are closely connected and a trigger in one can trigger the other as it is the same air flowing between the two areas of the body.

Your environmental blood tests were normal but there are hundreds of other articulates and pollutants that we currently can not test for and your symptoms do suggest something in the environment is triggering your symptoms.

In cases such as yours, it is reasonable to treat with both inhalers and a nasal spray in addition to singulair and other medications.

Assuming you are clinically stable and the symptoms do not effect your ability to live and function, the preference is always to treat with the least number of medications required. Your PCP's initial approach was correct and I note other medications were not added till later.

Unfortunately you are at the stage of disease where the condition is known but finding the optimal treatment

Comments / Follow Ups

Patient: Thanks for your detail reply.

Recently, I do feel better in general, both the congestion & post-nasal drip/itchiness. Plus the coughing fit & chest tightness are less frequent than few months ago.

I'm keeping a brief journal and I believe that the warmer weather (temperature change is a matter for me) is help a bit. It's getting warm in Southern California.

The neti pot at night seems makes me feel less congested in the morning (although it not completely goes away) so will keep doing it once per day plus taking my PCP's singular & Flonase. I don't use the albuterol that much.

Here is another question.

I notice that occasionally I feel a bit short of breath after a full meal. It's last for about 15-20 minutes but it's gradually goes away.

Is it normal to have this like of feeling? When should I pay attention and consult my PCP?

Again thank you so much for your time!

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