CASE
An 18-year-old male developed nasal congestion, fatigue, malaise, and mild dry cough at boarding school. Over the next week, his cough got worse, occurring in severe spasms. The patient felt like he was choking and could not catch his breath. Several times, he came close to posttussive vomiting. He had no shortness of breath, exertional dyspnea, postnasal drip, reflux, fevers, chills, or sweats. Only a codeine-based cough syrup provided relief. A school physician prescribed amoxicillin, followed by amoxicillin/clavulanic acid, prednisone, and albuterol, all to no avail.
The patient had no history of asthma, allergy, lung disease, tobacco use, or substance abuse. His roommate was not sick, but his mother had developed a similar syndrome after her son came home on break. The patient worked with horses. He had no other unusual exposures or history of recent travel.
On examination, the small-framed young man was in no acute distress. His temperature was 97.7ºF, and skin tone was normal. Tympanic membranes were gray and flat bilaterally, and the nasal mucosa was hyperemic. He had a deviated septum. The oral mucosa was pink and moist, and the tonsils were prominent but without active inflammation or exudate. No lymphadenopathy was noted. The chest was resonant to percussion, and lung sounds were clear bilaterally. He had no rales or rhonchi, and he was not wheezing or in respiratory distress. The cardiac examination was unremarkable. Laboratory studies and posteroanterior and lateral chest radiographs were obtained. The lateral radiograph is shown in Figure 1.
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