A 20-year-old male with a past medical history of gastroesophageal reflux, asthma, seasonal allergies, and well-controlled UC was referred to Otolaryngology clinic with chronic cough, hoarseness, and dyspnea. He had a persistent intermittent cough for three years with interval periods of resolution. The cough was intermittently productive for green sputum and worse during the night. He had several episodes of cough with associated dyspnea prompting visits to the emergency department. Prior to his presentation to Otolaryngology, the cough had been resolved for more than a year, but then began to worsen to the point that he could not talk, laugh, or exercise without coughing. He also began to have difficulty projecting his voice and occasional aphonia, and along with the worsening cough prompted a referral from his Pulmonologist to Otolaryngology for evaluation of vocal fold function, as there was a concern for paradoxical vocal fold dysfunction. His Pulmonologist had diagnosed him with habitual cough several years earlier with flexible bronchoscopy. The patient had also received several courses of low dose oral steroids, inhaled corticosteroids, albuterol, and antibiotics such as azithromycin and levofloxacin from the emergency department and pulmonologist for exacerbation of his cough. He experienced minimal relief of his symptoms with these therapies. His past medical history included UC diagnosed at age 16, overall well-controlled with oral mesalamine and mesalamine enemas without surgical intervention. He had gastroesophageal reflux treated with omeprazole and seasonal allergic rhinitis treated with cetirizine, nasal fluticasone, and nasal saline sprays. Patient is a lifetime nonsmoker. Prior workup for his chronic cough included normal pulmonary function tests, sputum culture growing normal respiratory flora, and several chest X-rays without persistent radiologic findings diagnostic for a specific etiology. A CT chest without contrast showed patchy ground-glass opacities in the left lower lobe with no consolidations, consistent with an atypical infectious or inflammatory process.

Upon presentation to Otolaryngology clinic, bedside stroboscopy showed generalized laryngeal erythema and thick yellow mucus in the subglottis and trachea (Figure 1). He was diagnosed with tracheitis and laryngitis and tried on a course of levofloxacin. After he failed to improve, he underwent microsuspension direct laryngoscopy with laryngeal biopsy and culture. Concurrent flexible bronchoscopy with bronchoalveolar lavage (BAL) was notable for erythema and white-yellow plaques on the tracheal wall, carina, and bilateral bronchi (Figure 2). Histology of the trachea showed respiratory and squamous mucosa reactive changes and marked chronic inflammation in the lamina propria. This suggested that the tracheobronchitis was an extraintestinal manifestation of ulcerative colitis. The BAL grew Streptococcus mitis, Staphylococcus aureus, Stomatococcus, Gemella sanguinis, and Haemophilus influenzae. He was treated inpatient with high-dose pulse IV steroids (1,000 mg methylprednisolone daily) for three days and ceftriaxone, with immediate, marked improvement of his cough. He was discharged home with a two-week course of Augmentin and one-month oral prednisone taper.

Repeat flexible bronchoscopy one month after his first procedure showed resolution of erythema and plaques. Patient developed recurrent cough two months after the prednisone taper, which was improved by a one-week course of prednisone 60 mg daily. Notably, he was able to tolerate a strenuous two-week hiking trip. Repeat stroboscopy at a four-month follow-up with Otolaryngology showed some minimal white mucus in the subglottis with no laryngeal erythema.