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Unexplained cough: it is time to rule out Sjogren’s syndrome

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Abstract

Sjogren’s syndrome is associated with chronic cough, but sicca symptoms are missing from cough evaluation guidelines. We evaluated patients with unexplained cough for undiagnosed Sjogren’s syndrome. Patients referred to our pulmonary clinic (Sheba Medical Center, 2009 to 2012) with unexplained cough and concomitant dry eyes were selected for evaluation. Unexplained cough was defined as chronic cough of unknown etiology despite algorithm-based evaluation and treatment. Patients were evaluated in a dedicated clinic by a pulmonologist, rheumatologist, and ophthalmologist specializing in autoimmune disease. Patients completed the Leicester Cough Questionnaire, spirometry, antibody testing for anti Ro/La, ophthalmologic examination with visual acuity, eyelid, ocular surface fluorescein staining, tear break-up time and Schirmer’s test, full slit lamp, and fundus examinations. Four-year follow-up was conducted by telephone questionnaire. We identified 24 patients among which 22 (21 females) agreed for evaluation. Eight patients (36%), seven initially, and one during follow-up were diagnosed with Sjogren’s syndrome (SS) (six secondary and two primary SS). At 4-year follow-up, cough tended to persist and improve in only 37% with SS. These include 2 (Scl and RA) who received rituximab and 1 (stage 1 sarcoidosis) with spontaneous improvement. In contrast, cough improved in most (64%) patients without SS; the majority (eight/nine) report intensified disease-specific treatment (five allergic and three GERD). We describe patients in whom unexplained chronic cough was associated with dry eyes. Focused workup revealed undiagnosed Sjogren’s syndrome in 36%. Dry eyes, with or without SS, is under-recognized and should be added to diagnostic algorithms for unexplained cough.

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Abbreviations

SS:

Sjogren’s syndrome

UIP:

Usual interstitial pneumonitis

LIP:

Lymphocytic interstitial pneumonia

MSGB:

Minor salivary gland biopsy

GERD:

Gastroesophageal reflux disease

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Acknowledgments

We sincerely appreciate the feedback and encouragement during our investigation from Dr. Burton Dickey of M.D., The University of Texas, M.D. Anderson Cancer Medical Center.

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Author notes

  1. Matthew Koslow and Shaye Kivity contributed equally to this work.

Authors and Affiliations

  1. The Pulmonary Medicine Institute, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel

    Matthew Koslow & Issahar Ben-Dov

  2. Fellowship, Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA

    Matthew Koslow

  3. Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st Street, SW, Rochester, MN, 55902, USA

    Matthew Koslow

  4. The Department of Internal Medicine A, the Zabludovicz Center for Autoimmune Diseases, and The Dr. Pinchas Borenstein Talpiot Medical Leadership Program 2013, Chaim Sheba Medical Center, Tel-Hashomer, Sackler Faculty of Medicine, Ramat Gan, Israel

    Shaye Kivity

  5. The Golschleger Eye Institute, Chaim Sheba Medical Center, Tel Hashomer, Sackler Medical School, Tel Aviv, Israel

    Vicktoria Vishnevskia-Dai

  6. Division of Pulmonary, Critical Care and Sleep Medicine, Yale University Hospital, New Haven, CT, USA

    Issahar Ben-Dov

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  1. Matthew Koslow
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Correspondence to Matthew Koslow.

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The study has been approved by the Helsinki committee of our institution. All persons gave their informed consent prior to their inclusion in the study. Details that might disclose the identity of the subjects under study should be omitted.

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Koslow, M., Kivity, S., Vishnevskia-Dai, V. et al. Unexplained cough: it is time to rule out Sjogren’s syndrome. Clin Rheumatol 37, 1215–1222 (2018). https://doi.org/10.1007/s10067-018-3987-4

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  • DOI: https://doi.org/10.1007/s10067-018-3987-4

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