Chronic cough and weight loss in a nonsmoking 56-year-old woman

A 56-year-old housewife seen at your office has a 3-month history of chronic, nonproductive cough, which has recently become unresponsive to over-the-counter liquid cough suppressants. She denies having shortness of breath, wheezing, chest pain, hemoptysis, fever, chills, sore throat, hoarseness, or postnasal drip. Her cough is independent of time of day, physical activity, weather conditions, and exposure to dust or household cleaning agents. Furthermore, her daughter’s cigarette smoke does not seem to aggravate the cough. She notes that she has been feeling fatigued and, without dieting, has lost 18 pounds over the past 6 months.

Her past medical history is noncontributory. She is a nonsmoker and nondrinker and does not come in contact with any known chemical substances or irritants other than typical household cleaning agents. Her father died at age 65 of a myocardial infarction, and her mother had breast cancer at age 71. Her first husband died of a cerebrovascular accident 3 years ago. Newly remarried to a retired shipyard worker, she and her current husband live with her 28-year-old daughter and 9-year-old grandson in their New Hampshire home. She has not been outside the New England area for the last 5 years.

Results of the physical examination, including HEENT and chest examination, were normal. There is no cyanosis or clubbing of the extremities, and there are no palpable lymph nodes. Blood tests, including a complete blood count and chemistry panel, are normal, with the exception of a total serum calcium level of 12.7 mg/dL (normal range: 9.2 to 11.0 mg/dL). However, a chest radiograph reveals a noncalcified, noncavitary 3.5-cm mass located within the parenchyma adjacent to the right hilum. There are no other radiographic abnormalities. Results of a PPD skin test for tuberculosis are negative. Urinalysis results are normal.

(a) What is the differential diagnosis for this woman’s condition?

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(b) What further testing might you order?

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(c) List several environmental causes that have been associated with this patient’s probable disorder.

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(d) What treatment options might you consider?

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Answers can be found on page 18.