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Posterior circulation stroke presenting as cough

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In the current scenario, with every symptom being attributed to COVID-19, a new continuous cough is no different. However, it must be noted that cough might be seen in neurological diseases as well.

Warraich and colleagues reported the case of a 19-year-old male, who was a non-smoker, usually fit, who presented with a 2-week history of continuous cough. He had no history of fever, recent travel or contact with a person with COVID-19. He had been in self-isolation due to this symptom.

A day before presenting to the hospital, the patient had developed a sudden onset disequilibrium, sense of vertigo, nausea and several episodes of vomiting while standing. There was a history of left facial paraesthesia and left-sided neck pain before presenting to the hospital, with difficulty in clearing his throat in the preceding days. The authors could not identify any prior vascular risk factor.

Neurological examination showed subtle left-sided incoordination of both upper and lower limbs and horizontal gaze evoked nystagmus. The patient had dysarthria and impaired swallowing caused by impaired laryngeal elevation. Features didn’t suggest Horner’s syndrome. Power was normal in all limbs and there was no objective sensory impairment.

The patient was isolated and tested for COVID-19 but the symptoms and examination indicated a brainstem lesion. 

Routine blood tests, including initial inflammatory markers, came out normal. ECG showed sinus rhythm. Transthoracic echocardiography showed no thrombus in left ventricle, no valvular lesions and no flow seen through the atrial septum. The COVID-19 nasal swab assessment was negative. Chest X-ray was within normal limits. Computed tomography(CT) of brain and CT angiography (CTA) of neck and brain were normal. 

MRI of the brain indicated diffusion restriction in left lateral medulla. However, there appeared to be a mismatch between the two diffusion weighted imaging(DWI) (b0 and b1000 sequences, respectively) and apparent diffusion coefficient (ADC) sequences. This pointed to a possibility of acute and subacute ischemic change. The radiological changes hinted that an event may have triggered the cough and a later extension led to significant neurological deficit causing the patient to seek medical care.

The patient was admitted to the stroke unit. His initial National Institutes of Health Stroke Scale Score was 2 and thrombolysis was not done. High-dose aspirin was given for the treatment of ischemic stroke, and the patient was switched to low-dose clopidogrel after 2 weeks. A nasogastric tube was inserted to support nutrition and medications. Nausea was controlled with metoclopramide, overlapped with gabapentin to treat hiccups.

On Day 3 of admission, he developed fever, hypoxia and shortness of breath. Chest radiograph showed a right lower lobe collapse and consolidation possibly due to aspiration. He was given intravenous amoxicillin, extensive chest physiotherapy and oxygen therapy. The patient recovered within the next few days.

The authors re-evaluated the patient’s presentation to determine if he may have had COVID-19-related ischemic stroke. However, the clinical and radiological features suggested aspiration secondary to dysphagia associated with brain stem strokes.

Reference

Warraich M,Bolaji P,Das S. Posterior circulation stroke presenting as a new continuous cough: not always COVID-19.BMJ Case Rep. 2021; 14(1): e240270.

What are the learning points?

In patients with recurrent cough and new neurological signs, a brainstem cause must be looked for.

Every cough, during this pandemic, should not be labelled to COVID-19.

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