Why a long cough with weight loss matters
In India, a long cough with fever, night sweats or weight loss must be tested for tuberculosis, and other causes, including cancer, kept in mind. The history also tells you about drug resistance, HIV and the people he lives with.
What to ask in the history
- How long the cough has lasted, sputum, blood in it
- Fever pattern, night sweats, weight loss, appetite
- Contact with anyone with tuberculosis; previous tuberculosis treatment
- HIV risk, diabetes
- Smoking, dust or fumes at work
- Which antibiotics he has already had
- Breathlessness, chest pain
- Who lives with him
Red flags
- Coughing up a large amount of blood
- Breathless at rest, low oxygen saturation
- Previous tuberculosis treatment
- HIV
- Severe weight loss
What to examine
- Weight, temperature
- Lymph nodes
- Clubbing
- Chest: crackles, bronchial breathing, signs of fluid
- Liver and spleen
First investigations
- Sputum for a rapid molecular test and smear
- Chest X-ray
- HIV test, glucose
- Full blood count, ESR
- Liver and kidney function before any treatment
- CT or bronchoscopy if sputum tests are negative and suspicion stays high
Differential diagnosis of a long cough with weight loss
Grouped, not ranked. Which one fits this patient is for you to work out in the case.
Infection
- Tuberculosis
- Pneumonia that has not settled
- Lung abscess
- Fungal infection
Cancer
- Lung cancer
- Lymphoma
Other
- Bronchiectasis
- Sarcoidosis
- HIV-related lung disease
Common mistakes
- Giving course after course of antibiotics instead of testing.
- Not testing for HIV and diabetes.
- Forgetting the people he lives with.