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Ask The Expert

May 5, 2014

Constant Itchy Throat with Cough

Question

I have a case to present. A woman who is 62 years old complained of constant itchy throat for many years. She tried many kinds of antihistamine drugs without good effect. I can't find any environmental factors influencing her disease. She has been to Australia without a change in symptoms. The SPT showed negative results. I prescribed 1st generation and 2nd generation antihistamines for her without good effect. I can't explain it. She does not have asthma nor allergic rhinitis, etc. She coughs sometimes because of the itching.Constant Itchy Throat with Cough

Answer

By Dr. Desiree Larenas-Linnemann and Dr. Gary Stadtmauer

Reviewing, we have a 62 year-old patient with a chronic complaint of an itchy throat and some cough that does not seem to improve with a change in environment nor with anti-histamines.

There are a few key elements and questions to think about regarding this patient's history. The first is the patient's age which suggests that the problem may not be atopy.

As we know, IgE-mediated allergic diseases decline with age. On the other hand, the prevalence of allergic conditions in elderly people has been augmenting, and recent estimates are that allergic rhinitis affects up to 15% of persons aged 60-70 [1]. Although the above information seems to discard allergy as a cause of her symptoms, we would not rule out allergy from the beginning. Thus, an element of the history is to know whether the patient has any other nasal symptoms suggestive of allergy or sinus disease. Lastly, we would inquire further as to more details about the itch. Is it truly an itch, or does the patient have more of an irritative sensation in the throat? The cough may or may not be relevant, and further questioning is helpful. Is the patient intentionally coughing to relieve the throat symptom?

Several additional details might help us out somewhat further:

  1. Where does she normally live? Is her exposure to environmental factors at home very different from the environment in Australia where she went to?
    1. Where in Australia did she go, as the Northern part (sub-tropical = mostly mites) is very different from center (dry, hot = pollen/mold) and from the Southern part (more temperate =all)?
       
  2. Also: “for many years” . . . does this mean during the whole year or worse in a certain season?
     
  3. What anti-histamines, what dose, for how long? Some patients treated with anti-histamines may improve when treated with somewhat higher doses. Other patients do improve while they take anti-histamines, but as they relapse after discontinuing the medication they come to their doctor saying ‘they did not improve at all’, which might be confusing for the treating physician. It is important to explore this in detail to find out if it is really true that while taking a potent anti-histamines at the right dose (or even double dose) the symptoms stay the same.
     
  4. Post-nasal drip is one of the symptoms of allergy, not so easy recognizable but sometimes quite resistant to systemic anti-histamines. A trial with topical anti-histamine in combination with a topical nasal corticosteroid would be worth a try to rule this out.
     
  5. SPT negative results: it is important the SPT was done with the right allergens and bought from the right provider (good potency, to reduce as much as possible false negatives). That’s why it is mandatory for the emission of good advice to know where the patient lives. For example, in the (sub) tropical zones of the far East, dust mites are the most important allergens. But, not only of the Dermatophagoides family [2-4]. As there are other mites also of importance over there, a SPT negative for HDM does not rule out the presence of a possible HDM allergy to one of the other mites (Blomia tropicalis, Lepidoglyphus, Acarus siro, etc.) that do cross-react in certain degree, but they do have their own specific allergens as well. [5]

Apart from allergy, itchy throat can be caused by:

Concluding, as for the work-up of this patient we would suggest: If correct skin testing with the locally present allergens in right concentrations is negative and there is no response to oral antihistamines then we would try a nasal steroid, nasal antihistamine or combination of the two. If this does not help and a brief burst of prednisone10 days does not relieve symptoms either then it's safe to say that the origin is not at all allergic. As to the workup, our next procedure would then probably be a rhinolaryngoscopy. It is possible that this patient has chronic rhino-sinusitis manifested solely as an itchy throat with occasional coughing. Another possibility would be laryngo-pharyngeal reflux which may be identified endoscopically. Finally, eventually the very rare causes- see above- could be considered.

References:

  1. Wuthrich B, Schmid-Grendelmeier P, Schindler C, Imboden M, Bircher A, Zemp E, et al. Prevalence of Atopy and Respiratory Allergic Diseases in the Elderly SAPALDIA Population. Int Arch Allergy Immunol. 2013;162(2):143-8. Epub 2013/08/08.
  2. Fonseca Fonseca L, Diaz AM. IgE reactivity from serum of Blomia tropicalis allergic patients to the recombinant protein Blo t 1. Puerto Rico health sciences journal. 2003;22(4):353-7. Epub 2004/02/11.
  3. Arlian LG, Morgan MS, Neal JS. Dust mite allergens: ecology and distribution. Curr Allergy Asthma Rep. 2002;2(5):401-11. Epub 2002/08/08.
  4. Vidal C, Boquete O, Gude F, Rey J, Meijide LM, Fernandez-Merino MC, et al. High prevalence of storage mite sensitization in a general adult population. Allergy. 2004;59(4):401-5. Epub 2004/03/10.
  5. Morales-de-Leun G, Lupez-Garcia A, Arana-Muooz O, Carcaoo-Perez Y, Papaqui-Tapia S, Caballero-Lupez CG, et al. [Correlation of cutaneous reactivity between allergenic extracts of Dermatophagoides pteronyssinus and Dermatophagoides farinae with Blomis tropicalis in patients with allergic rinitis and asthma]. Rev Alerg Mex. 2012;59(3):107-12. Epub 2012/07/01. CorrelaciUn de reactividad cut.nea entre extractos alergEnicos de Dermatophagoides pteronyssinus y Dermatophagoides farinae, con Blomia tropicalis en pacientes con rinitis alErgica y asma.
  6. Khalil G, Haddad C, Otrock ZK, Jaber F, Farra A. Halzoun, an allergic pharyngitis syndrome in Lebanon: the trematode Dicrocoelium dendriticum as an additional cause. Acta tropica. 2013;125(1):115-8. Epub 2012/10/02
  7. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. [A case of parasite in throat with laryngeal itching and cough as the first symptom]. [Article in Chinese] 2011 Aug; 46(8):692-3.

Desiree Larenas-Linnemann, MD
Clinic of Allergy, Asthma and Pediatrics Hospital Medica Sur
Mexico City, Mexico

Garry Stadtmauer, MD
City Allergy
New York, New York, USA


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