University of Saskatchewan
Correspondence to: D. W. Cockcroft, MD, FCCP, Division of Respiratory Medicine, Royal University Hospital, 103 Hospital Dr, Ellis Hall, Saskatoon, Saskatchewan, S7N 0W8 Canada
To the Editor:
I read with interest the valuable article by Pratter et al
(November 1999),1 regarding the role of sinus imaging in
the management of chronic cough. Figure 2 in this article contains a
useful algorithm for investigation and treatment of chronic cough.
Unfortunately, one potentially important cause of cough will be missed
by following this algorithm.
Eosinophilic bronchitis is a recently described
syndrome.2–4 Subjects with eosinophilic bronchitis have
cough with eosinophilic airway inflammation characteristic of that seen
in asthma; however, these patients have normal lung function, negative
methacholine challenges, and no evidence of variable airflow
obstruction. The cough in this condition responds nicely to inhaled
corticosteroids.2–4 This syndrome would appear to be a
precursor to (or perhaps the very mildest form of) symptomatic asthma.
While the “purists” would not include this within the umbrella of
the label asthma, it seems reasonable to consider that this
is a variant of the syndrome known as cough-variant asthma. In a recent
study,,4 corticosteroid responsive eosinophilic bronchitis
with negative methacholine challenge was shown to be present in 13% of
subjects with chronic cough.
The authors have pointed out the poor predictive value of a positive
methacholine challenge in predicting response to asthma
therapy.1,5 The relative common prevalence of eosinophilic
bronchitis as a cause of cough underscores that a negative methacholine
challenge is also a poor predictor of nonresponse to inhaled
There are two important messages. First, this questions the value of
the routine use of methacholine challenges in the evaluation and
management of chronic cough. It is possible that a brief diagnostic
trial of high-dose inhaled corticosteroids might be a preferable tool
at step 2 of the cough algorithm. Second, it suggests the potential
value for standardized evaluation of sputum for inflammatory cells,
particularly eosinophils, in arriving at a diagnosis and the management
plan for cough.
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