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Background
Cough is a common presentation in all areas of medicine. There is a wide differential and often the cause is respiratory or cardiac in origin. In primary care initial investigations can be performed and it is not unusual to trial treatments for common causes. This includes gastro-oesophageal reflux, postnasal drip and asthma. 1 This is dependent on investigations and clinical suspicion. 2 Rarer causes must also be considered especially when there is treatment failure. Cough has been reported to be secondary to thoracic aortic aneurysms in the literature. 3 It is presumed to be secondary to bronchial compression from local mass effect. 4
We present a patient with a bicuspid aortic valve, thus prone to aortic root enlargement, presenting with chronic cough with no apparent cause. Given widening of the mediastinum on his chest radiograph in conjunction with his new symptoms there were concerns there may be local compression from a thoracic ascending aortic aneurysm. Urgent imaging was requested which revealed the diagnosis. There had been a significant delay of 8 months to diagnosis, which is considerable when there was a clear risk factor. Timely diagnosis of thoracic aneurysm is important given that early medical or surgical intervention can prevent the considerable morbidity and mortality associated with rupture and dissection.
Case presentation
A 73-year-old man had been referred to secondary care, including a cardiology clinic, by his general practitioner (GP) for further clinical assessment of his chronic cough. He had a background of a bicuspid aortic valve for which he had had a metallic aortic valve replacement in 2002 for mixed aortic valve disease. He also had a medical history of atrial fibrillation. The patient was a non-smoker with no history of asthma. His regular medications included bisoprolol and warfarin.
He had been experiencing chronic cough for approximately 8 months. The cough was predominantly dry but occasionally productive of clear sputum. The cough occurred at rest and on exertion. There was associated voice hoarseness in the preceding months. No chest pain, haemoptysis or wheeze had been reported.
He had been treated with proton pump inhibitors, steroid nasal sprays and steroid inhalers for some time by his GP with no success in alleviating his symptoms. He had also been referred for a chest radiograph and...