Correct!
5. All of the above

She has not responded to the nasal corticosteroid therapy and according to the CHEST guidelines she has developed a “red flag”, in this case the fever, suggesting that further investigation is warranted. Other “red flags” are listed in Table 1.

Table 1. “Red Flags” in chronic cough evaluation (1).

• Hemoptysis
• Smoker > 45 years of age with a new cough, change
• in cough, or coexisting voice disturbance
• Adults aged 55-80 years who have a 30 pack-year smoking history and currently smoke or who have quit within the past 15 years
• Prominent dyspnea, especially at rest or at night
• Hoarseness
• Systemic symptoms
• Fever
• Weight loss
• Peripheral Edema with weight gain
• Trouble swallowing when eating or drinking
• Vomiting
• Recurrent pneumonia
• Abnormal respiratory exam and/or abnormal chest radiograph coinciding with duration of cough

It should be remembered that up to 15% of patients taking lisinopril can develop a chronic cough (2). However, this would be unlikely to cause fever. Certainly, with the COVID-19 pandemic occurring testing for COVID-19 should be performed because of her fever. It was negative. A repeat chest x-ray and sinus imaging are reasonable looking for a source of the cough and fever. Some might also perform a sputum for eosinophils to evaluate for non-asthmatic eosinophilic bronchitis (NAEB). However, in our experience sputum evaluation of sputum eosinophilia is difficult to perform and requires care in collecting the sputum and experience selecting the portion of the sputum to evaluate.

Sinus imaging was unremarkable.

The repeat chest radiography is shown in Figure 2.

Figure 2. Repeat chest PA (A) and lateral (B) radiography.

Which of the following are true regarding the repeat chest X-ray? (Click on the correct answer to be directed to the fourth of seven pages)

1. There is a new left lung mass
2. There is a new left pleural effusion
3. There is a new right lung mass
4. There is a new right pleural effusion
5. There is no change

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