Dear Gurmohan Singh,
Thank you for your query at DoctorSpring.com
I understand your apprehension and that you are troubled with your symptoms. I also understand that you have already had more than enough with consultations and consultants, of which you gained nothing.
First of all, let me make it clear- CRP is highly non specific. It can be elevated in noon infectious causes like obstructive sleep apnoea also. So as with any other patient, I suggest not to treat a lab report, but treat the patient and symptoms.
Has the temperature been recorded anytime? What do you mean by low grade fever. Is it associated with chills and rigor?
As your whole symptoms revolve around respiratory system, I suggest it's better not to go in search for any other focus. I am frankly not aware why you should be I investigated for this and that !!
Crp as I mentioned is non specific. And ct being normal, I rule out most of the infections of lung and sinus. Before ruling out all infections, I would like to rule out h pylori infection of stomach. Also I prefer to do a procalcitonin to make sure it's An infection.
So to the long list, I add 2 more investigations- A procal and h pylori and sputum culture and sensitivity (repeat)
In case you are bored of investigations, I suggest treatment with HP kit, a proton pump inhibitor, prokinetic agent, and anti histaminics like cetrizine and cough suppressants. It should help.
Dr. Jacob George P
MD IDCCM FCCP
Patient replied :
Dear Dr Jacob George P,
Thank you for your prompt response.
Firstly I would like to answer your queries:
1. Has the temperature been recorded anytime? What do you mean by low grade fever. Is it associated with chills and rigor?
Yes I frequently record my temperature. It is associated with Chills and Rigor. During and after chills and rigors, my temperature goes anywhere between 37.5 - 39.0
I welcome your approach and suggestion regarding 2 more investigations ( A procal and h pylori) however my problem is particularly related to Yellow sputum which has been present for over 6 months now. Even with the strongest antibiotics available in Australia to treat this type of infection has not worked. Being on Antibiotics my sputum production actually aggregates i.e more production of sputum which causes other problems such as difficulty breathing etc.....
It may be well possible that these two conditions which you have mentioned may be adding up to the problems so I'll surely get my local GP to have them checked out... As soon as I've the results I'll share.
My GP rang me late last night to say that my WCC have come up high (19) along with the high CRP which I previously mentioned was 132 mg/L
I believe that my GP is now planning to send me back to Infectious Disease department in the hospital as he and other specialists have exausted their medical resources and don't want to keep giving me antibiotics again and again.
Whilst I've been seen by the Infectious Disease department three times during my addmission into the Hospital I'm not sure what extra can they do or have in their mind. I'm completly sick and tired of being in the Hospital now.
I would greatly apprecaite if you could please consult your Infectious Disease specialist and perhaps someone in Respiratory for a second opinion.
Thank you again and I look forward to hearing from you soon.
If the wbc count are high, we need a peripheral smear also.
I don't doubt the significance of the fever.
Kindly get procal also.
H pylori won't cause fever ideally. But it can worsen cough.
Hope your urine also is normal and has been tested. Same with teeth and gums. Hope there is no caries or gum problems.
Last resort will be a whole body ct / MRI / pet to diagnose it.
For time being, I suggest repeat sputum culture and sensitivity, antibiotics accordingly as we don't have any other system that seems to be affected.
Patient replied :
Hi, As suggested by you, I've had the following tests done which have (ALL) come Negative:
- H Pylori
- Sputum Culture and Sensitivity
- Whole Body CT Scan (with Contrast)
I would like you to please refer me to an Infectious Disease Doctor to your immeidate availabilty. Thank you. Regards, Gurmohan
Hello Mr. Gur Singh,
I am Dr. Deepu and I am pleased to assist you.
One consistent finding in all your reports is that there is a lot of gram positive cocci in your sputum which has been persistent. And it is not an external infection, rather your own flora seems to be causing the problem. Every human being has bacteria in all their mucosal areas, which stay in harmony with the body. They can only overgrow when antibiotics kill the other group od bacteria responsible for infections.
Yes your case is slightly confusing because you have been given antibiotics and still it has not helped. At least the IV antibiotics should have helped you but even they have not been helpful.
This does not seem to be related to any auto immune pathology and hence I won't suggest further testing.
Sometimes such cough can also be caused by persistent post nasal drip ( chronic sinus infection ) which has absolutely no symptoms apart from a post nasal drip and the patient manifests with persistent sore throat and cough with sputum. Did you get a X-RAY of your PNS? If so, can you mention the findings?
Also there is an exhaustive list, but I want you to list your current symptoms in brief as of now, and also the names of antibiotics you have already tried. Looking forward to hearing from you,
Patient replied :
Dear Dr. Deepu,
Thank you for your prompt response.
Response as requested:
- CT Scan of Sinus already done and was Normal. It is attached in the files that I provided earlier.
- Antibiotics - Ciproxin 750 mg, Clarithromycin, Doxycycline 100mg & Curam Duo Forte (amoxycillian 875mg / Clavulanic acid 125mg). At the moment I've been on Curam Duo Forte for almost 3 weeks with another week to go.
My Current Symptoms:
- Mucus - Yellow Colour (heavy growth)
- Low fever and chills (random though). Fever goes upto 38
I'm attaching my investigations for the month of Jan 2015 for your reference which includes recent CT scan of Chest and Abdominal.
I've been referred by my lung specialist to see a Infectious Disease specialist as he has exausted his expertise. Unfortunately the earliest appointement that I can get from an ID specialist is early May.
Look forward to hearing from you.
Dear Gur Singh,
Thank you for the follow up.
It is extremely unfortunate that you are suffering for so long. You have tried almost all medicines and still have had no respite. All your reports are normal too, leaving your primary doctor clueless about what needs to be done.
I do have a few things to add, which I want you to discuss with your physician.
Now that the cough has persisted over 6 weeks, you seem to have chronic bronchitis, where in some rare cases cough persists for a really long time, even months. What chronic bronchitis does is since the bronchi is almost always inflamed, it provides a nidus for viral/ bacterial infection to occur. It can attract different organisms, so not one but multiple organisms can be growing at the same time. It does get better on taking antibiotics, but unfortunately that has not happened in your case.
I want you to discuss with your physician about the possibility of using steroids to control your cough. I feel if we can control your cough, indirectly meaning the inflammation in your bronchi reduces, it will let your bronchus heal and the persistent infection nidus will not be there. Along with steroids, I also want you to try Montelukast-LC for a period of 2 weeks, once before sleeping. This will also reduce the mucoid secretion and let it drain fast.
My objective now is to make sure your secretions drain fast rather than trying to find out what organism is growing because that has been tried. You should also use a cough syrup like Ascoril/ Codeine twice daily along with Montelukast and steroids.
Please discuss this from my angle with your physician. This is a different route, but I sincerely hope this helps you.