A rare case of bilateral cough rib fracture due to an uncommon upper respiratory cause

Dear Sir, Cough is a common cardinal symptom of numerous respiratory and upper airway pathologies. The forceful expiration phase of cough brought about by the sudden strong contraction of the expiratory muscles can push the air out of the lung at velocities nearing 965 km/h.[1] This forceful expiration phase can raise the intrapleural pressures to as high as 100 mm of Hg and exert stress on the ribs to which the intercoastal muscles are attached.[2] Repeated cycles of stress brought about by chronic cough can cause micro-fractures in the ribs which in turn can progress to displaced and undisplaced fractures.[3] The sixth rib is the most fractured rib due to chronic cough with 25% of patients having bilateral rib fractures. The most common causes of cough-induced rib fractures are post-infectious cough (35%), postnasal drip (33%), chronic bronchitis (24%), gastroesophageal reflux (22%), asthma (19%), and acute respiratory tract infections (15%).[4] Laryngopharyngeal reflux even though a common upper airway cause of chronic cough has only been rarely associated with cough rib fractures.[5] We herein present a case who was diagnosed to have bilateral cough fracture of ribs caused by laryngopharyngeal reflux. 42-year-old woman, never-smoker, with no medical or surgical comorbidities presented to this center on June 2023 with complaints of chronic cough since April 2023. The cough was insidious in onset, non-productive and was not associated with diurnal, seasonal, or postural variation. The cough was triggered by exertion, laughing, and lying flat on the bed. She gave no history of breathlessness, wheezing, hemoptysis, fever, or weight loss. Since June 2023, she started experiencing chest pain which was initially localized to right lateral hemithorax but progressed to involved bilateral hemithorax within a week. The pain was sharp, non-radiating and aggravated by coughing and deep breaths. There was no history of trauma to the chest. The patient did not seek medical help for the cough but the distress caused by the chest pain brought her to our outpatient department for medical care. On clinical examination, her vitals were stable and she had a body mass index of 19 kg/m2. The patient had tenderness in her bilateral infra-axillary region with other chest examination findings being essentially normal. There was no clinical evidence of tuberculosis, obstructive airway disease, or interstitial lung disease. On evaluation, complete blood count demonstrated a hemoglobin level of 11.8 g/dL, total leukocyte count of 9700 cells/mm3 (neutrophils 50%, lymphocyte 47%, monocyte 0%, eosinophil 3%), and platelet count of 3,25,000 cells/mm3. Serum biochemistry revealed urea 28 mg/dL, creatinine 0.95 mg/dL, total bilirubin 0.7 mg/dL, AST 19 IU/L, ALT 20 IU/L, sodium 140 meq/L, potassium 3.5 meq/L, and corrected serum calcium 7.2 meq/L. Sputum gram stain and Ziehl Neelsen stain were negative. Tuberculin skin test was negative with an induration less than 5 mm. Chest radiograph demonstrated consolidating fracture in the anterior aspect of the bilateral 6th rib. High-resolution computed tomography was done which confirmed these findings [Figure 1]. As the patient had no evidence of lower respiratory pathologies causing cough an otorhinolaryngologist review was taken. Hopkins laryngoscopy performed on the patient demonstrated endo-laryngeal inflammatory changes in the form of diffuse endolaryngeal erythema, posterior commissure hypertrophy and thick endolaryngeal mucus [Figure 2] with a reflux finding score of eight.[6] In view of chronic cough and laryngoscopic findings, she was diagnosed to have laryngopharyngeal reflux. She was managed conservatively with analgesics, cough suppressants, proton pump inhibitors, and lifestyle modifications.Figure 1:: High-resolution computed tomography of chest demonstrated consolidating fracture in the anterior aspect of the bilateral 6th ribFigure 2:: Hopkins laryngoscopy revealing diffuse endolaryngeal erythema, posterior commissure hypertrophyCough-induced rib fractures are among the most common stress fractures of bones.[7] The underlying mechanism involves shearing stress exerted by the intercoastal muscles at the point of greatest rib curvature. It has been predominantly reported in women and can occur in any age group.[8] Osteopenia is usually reported in patients with cough rib fractures, although cases with normal bone density have also been reported. Our patient could not be evaluated for osteopenia due to resource limitations. The patients classically present with localized chest pain associated with chest wall tenderness following episodes of cough. Chest radiography can frequently miss costal arch fractures due to which a computed tomography is often necessary for diagnosis. The key in the treatment of cough rib fracture is the treatment of the underlying cause of chronic cough. The patient usually ignores the cough and typically seeks medical care for the pain and discomfort caused by rib fractures. Any non-traumatic rib fracture encountered by the physician should be evaluated for a history of cough preceding the event. Patient should be completely evaluated for lower respiratory and upper respiratory causes of cough and the underlying cause should be actively managed to favor the healing of rib fracture. Compliance with ethical standards The authors have no conflict of interest to disclose. Informed written consent of the patient was obtained for the publication of his medical information. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.