D2.179 - Chronic cough triggered by industrialised milk and wheat products

A 13 year-old boy proceeds for allergology evaluation due to chronic cough. He has been examined by a pulmonologist who has concluded that pulmonology evaluation was normal.

He has a constant cough since many years ago. He has the sensation that something disturbs him in breathing at the gorge.

The mother can not say if he coughs during night. However, he has a secondary nocturnal enuresis since many years ago. At the spirometry that we effectuate in the allergology consultation, he can not fully cooperate, and it is normal.

A blood analysis reveals: an increased HOMA index at 3,3 (n.v.: <2,4) with normal total cholesterol, LDL and HDL values and decreased triglycerides at 0,4 g/L (n.v.: 0, 48-2,19), increased LDH at 277 U/L (n.v.: <270), and Eosinophilic Cationic Protein at 24,7 µg/l (n.v.: 13,3), a decreased transferrine at 2, 32 g/L (n.v.: 2,38-3,66), and prealbumine at 0,15 g/L (n.v.: 0,2-0,4) and aldosterone at 137 pmol/L (n.v.: 144-677). The amino acid plasma chromatography revealed decreased cystine at 16 µmol/L (n.v.: 36-61), lysine at 94 µmol/L (157-242), leucine at 82 µmol/L (n.v.: 101-159), citrulline at 21 µmol/L (n.v.: 23-39). The urine amino acid chromatography revealed increased levels of glycine at 217 µmol/mmol creat (n.v.: 64-165), and 1-methylhistidine at 203 µmol/mmol (n.v.: 5-125). Creatinine urinary was decreased at 13,21 mmol/L /1,49 g/L.

The Respiratory Polygraphy (PG) at home revealed that the child had a mild apnea hypopnea syndrome (AHI: 2, 6n/h), although he did not keep the nasal flow signal. However, he had a Respiratory Effort (RE) during sleep increased at 21.7% (n.v.: 0-10) and a moderately increased index of arousability at 17.2n/h (n.v.: 0-10).

The Polysomnography (PSG) at home confirmed that the child had no apnea hypopnea syndrome (AHI: 2n/h), but he had a decreased sleep efficacy at 69% with a number of intra-sleep arousals increased at 41n ,  and a total duration of intra -sleep arousals increased at 203 min. The percentage of REM sleep was decreased (10.6%) and the N2 sleep was increased (52.2%).   

The subcutaneous capnography revealed that the child passed 9% of sleeping time therefore 33 min 51sec with a PCO2>50mmHg. He reached a max level of PCO2 increased at 86.0 mmHg. The oximetry also revealed that the child passed 16sec with a SpO2 decreased at <88%. He passed 4h22min44sec with a SpO2 decreased at 87%.

The child was set on Continuous Positive Airway Pressure (CPAP) which he accepted progressively.

In parallel, the patch tests were strongly positive for butter, margarine and wheat. He also had positive patch tests for Polysorbate 80 (E433). He was set in an eviction diet for industrial milk products and he stopped coughing. 

Moreover, once being set on CPAP and followed the eviction diet, the nocturnal enuresis ceased. However, when he ate ice cream or a milk chocolate he started coughing again.The child could not respect the eviction diet and discontinued the CPAP. The cough re-occurred when he ate an ice cream or industrialised desserts and cakes.