Zur Differenzialdiagnose des quälenden psychogenen chronischen Hustens: neuropathischer Larynx irritable – Gabapentin als Antitussivum

 

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Zusammenfassung

Vorgestellt wird der Fall einer 76 jährigen Patientin, die parallel zu einer schweren depressiven Episode im Anschluss an eine starke psychische Belastung erstmals in ihrem Leben chronisch quälende Hustenattacken entwickelte, die nach umfassendem und leitliniengerechtem Ausschluss alternativer Ursachen zunächst für psychogen gehalten wurden. Mehrere Faktoren ließen jedoch an der rein psychischen Genese des chronischen Hustens zweifeln: i) direktes Auftreten im Anschluss an eine hartnäckige Erkältung, ii) Einbettung in weitere Symptome der laryngealen Hyperreagibilität (Larynx irritable) wie ständiger Globus pharyngeus, Räusperzwang sowie episodische Dysphonie, iii) erstmaliges Auftreten im höheren Alter, iv) Hustenattacken auch aus dem Schlaf heraus, v) Persistenz trotz Remission der schweren depressiven Episode, vi) keine nachhaltige Besserung trotz gezielter Psychotherapie und Sprachtherapie. Deshalb wurde die Zusatzdiagnostik um die apparative Schluckdiagnostik mittels Videoendoskopie (FEES) und Videofluoroskopie des Schluckens (VFS) erweitert. Damit wurden Zeichen einer laryngealen Neuropathie allerdings ohne Nachweis einer Penetration oder Aspiration gefunden. Eine gleichzeitig vorhandene Struma und Glukosetoleranzstörung mit einem eventuellen intrazellulären Vitamin B12 oder Folsäuredefizit bei auffälliger Hyperhomocysteinämie wurden als zugrundeliegend angenommen und jeweils gezielt behandelt. Die Glukosetoleranzstörung und das angenommene Vitamindefizit passten auch zu einer noch subklinischen distal-symmetrischen sensomotorischen Polyneuropathie der unteren Extremitäten. Der Beschwerdekomplex des Larynx irritable profitierte gut von Gabapentin, wie in mehreren Absetzversuchen bestätigt werden konnte, und beruhigte sich schließlich annähernd komplett unter Gabapentin. Eine Kontrolluntersuchung der Larynxverhältnisse per FEES zeigte 9 Monate später rückläufige Defizite unter der gut tolerierten Behandlung (Gabapentin, Levothyroxin, Vitaminsubstitution, Gewichtsreduktion und körperliches Training). In der Zusammenschau war der Larynx irritable am ehesten durch eine laryngeale Neuropathie und nicht primär psychisch bedingt. Eine Berücksichtigung dieser mutmaßlich unterdiagnostizierten und auch literaturbasiert beispielsweise mit Gabapentin gut behandelbaren Störungen (Larynx irritable, laryngeale Neuropathie) wird bei der Ursachensuche für chronischen Husten zusätzlich empfohlen, bevor eine rein psychogene Ursache angenommen wird. Ein hypothetisches Schema der Entstehung eines Larynx irritable durch neuropathische und nicht-neuropathische („nozizeptive“) Bedingungen wird in Anlehnung an die bisherige Literatur angeboten.

Abstract

We present the case of a 76 year old female inpatient who suffered from a chronic intractable cough which arose simultaneously to a severe major depression and was secondary to an exorbitant psychological distress. Chronic cough had never been experienced before and was initially considered to have a mere psychogenic origin since a comprehensive and guideline-based diagnostic screening did not reveal any underlying somatic cause. However, several factors cast doubt on the solitary psychic genesis of the chronic cough: i) occurrence immediately after a penetrant cold, ii) embedding in other complaints of laryngeal hyperreagibility (larynx irritable), such as persistent globus pharyngeus sensation, throat clearing and episodic dysphonia, iii) first occurrence on old life, iv) erupting from sleep as well, v) persistence despite remission of the major depression, and v) no sustaining benefit from specific psychotherapy and speech therapy. Therefore, diagnostics were extended to apparative tools for objective evaluation of swallowing by using fiberoptic videoendoscopic (FEES) and videofluoroscopic (VFS) techniques, which revealed signs of laryngeal neuropathy but without evidence of penetration or aspiration. A co-existing small goiter and an impaired glucose tolerance along with a putative intracellular vitamin B12 or folate deficiency (as indirectly derived from an apparent hyperhomocysteinemia) were assumed to be responsible for the neuropathy and underwent specific treatments. The impaired glucose tolerance and putative vitamin deficit were compatible with a distal symmetric sensorimotoric, even subclinical polyneuropathy of the lower extremities. The larynx irritable improved under gabapentin being confirmed by drug removals several times, and finally calmed down almost completely under gabapentin, which was in line with the scant literature of this topic. Re-examination of the larynx per FEES nine months later showed no deficits any more under the well-tolerated treatment (gabapentin, levothyroxine, vitamin B12 and folic acid substitution, weight reduction and physical training). All in all, the larynx irritable as well as the chronic cough were most probably induced by a laryngeal neuropathy and were not solely of psychic origin. Due to good treatment options a larynx irritable should be regularly taken into consideration of the investigation of intractable chronic cough. Therefore, an apparative evaluation of deglutition is recommended in the diagnostic toolbox of chronic cough – even if embedded in a psychiatric disorder or distress – before diagnosing a sole psychic origin. An hypothetical scheme of the development of a larynx irritable caused by neuropathic and non-neuropathic ("nociceptive") conditions is proposed.

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