Biapical Lung Scarring with Chronic Cough: Diagnostic and Treatment Considerations

Introduction to Biapical Scarring

The American Thoracic Society recommends that post-TB complications, including bronchiectasis, endobronchial abnormalities, or retained sutures, be considered as causes of chronic cough in patients with biapical lung scarring 1, 2
Sarcoidosis can present with apical scarring and chronic cough, and should be considered in the differential diagnosis 1

The American College of Chest Physicians suggests that a high-resolution CT scan is essential to characterize the apical scarring pattern and identify complications like bronchiectasis, cavitation, or endobronchial lesions 3
Bronchoscopy should be considered if hemoptysis is present, or if there is concern for endobronchial tumor or retained foreign material 6, 7

The American Thoracic Society recommends that patients with suspected or confirmed active TB initiate multi-drug anti-tuberculous therapy per standard protocols, and that smokers be advised to cease smoking 3, 4, 5
If a patient is taking an ACE inhibitor, it is recommended to switch to an alternative antihypertensive, as ACE inhibitors can cause chronic cough with a median resolution time of 26 days 3, 4, 5
Empiric treatment for common causes of chronic cough, including upper airway cough syndrome (UACS), asthma, and gastroesophageal reflux disease (GERD), should be systematically undertaken, even in the presence of abnormal chest radiographs 1, 2, 8

Non-asthmatic eosinophilic bronchitis (NAEB) should be considered early in the diagnosis, as it responds predictably to inhaled corticosteroids 1, 2, 8
Pulmonology referral is recommended if cough persists despite sequential empiric therapy 5
Uncommon causes of chronic cough, including tracheobronchomalacia, airway stenosis, broncholithiasis, and retained foreign material, should be considered in refractory cases 9