Cough in children

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Marufa Marium, M.B.B.S[2]

Synonyms and keywords: Cough in kids

Historical Perspective

• The word Cough was first derived from the middle English Coughen or old English Cohhian which was primarily composed of the middle Dutch Kochen and the high middle German Kuchen, in early 14th century.

Classification

• Cough in children may be classified or defined according to the duration of presenting complaints, quality and sound, causes of cough into several groups.:
• 1 Duration of Presenting complaints: According to the duration of cough, it can be sub classified into three categories.
  • Acute: Cough persists for less than three weeks.
  • Subacute: Cough persists for three to eight weeks.
  • Chronic: Cough persists for more than eight weeks.

• 2. Nature or Quality and sounds: According to the quality and sound cough can be sub classified in to following categories-
  • Dry or Hacking or Nonproductive.
  • Wet or productive cough.
  • Staccato or short repetitive cough.
  • Whooping or paroxysmal violent or spasmodic cough.
  • Barking cough: Brassy barking or Honking barking.
  • Phlegmy cough.
  • Burning cough.

• 3. Causes of Cough: Based on causes cough is subdivided into following three sub groups-
  • Normal or expected cough.
  • Specific cough.
  • Non-specific cough.

• 4. Anatomic classification on causes of cough: Cough can be produced from different anatomical locations. for example-
  • Nose and Paranasal sinuses.
  • Pharynx.
  • Larynx.
  • Trachea and Bronchi.
  • Pulmonary parenchyma.
  • Pleura.
  • Mediastinum.
  • Heart and blood vessels.
  • External ear and Tympanic membrane.
  • Esophagus.

• 5. Grades of cough: Cough can be graded into four main sub categories-
  • Eutussia or Normal.
  • Hypertussia or Sensitized.
  • Hypotussia or Desensitized.
  • Dystussia or Pathological.
  • Atussia or Absent.

Cough in children can also be classified under infectious (Bacterial, Viral, fungal, Parasitic) or non-infectous categories broadly.

Pathophysiology

• Cough is natural innate primitive reflex that helps in mucocilliary clearance of foreign particles and secretions from respiratory tracts. It is also a defensive mechanism protecting respiratory airways from aspiration of pathogens, particulates and secretions. A complex arc comprised of neuro-respiratory pathways helps in initiating the cough reflex.

Mechanical and chemical stimulation of cough receptors (Rapidly adapting receptors, slowly adapting receptors or C-fibers) in Respiratory airways

Afferent pathways: Sensory nerve fibers via Vagus Nerve from ciliated columnar epithelium of upper airways, cardiac and esophageal branches from diaphragm send impulse to central cough center

Central cough center in upper brain stem medulla and pons send impulse of sequence of phases (Inspiratory, Compressive, Expiratory) for constituting cough

Efferent pathways: The nucleus retroambigualis sends impulse via phrenic and spinal motor nerves to diaphragm and abdominal and respiratory muscles, the nucleus ambiguous sends impulse to larynx by laryngeal branches of vagus nerve

• On gross pathology, Bloody, Serous , Mucoid, Rusty, Pink frothy, and Purulent are characteristic findings of sputum produced by coughing.
• On microscopic histopathological analysis, Pathogens, RBCs, Leukocytes, epithelial celss are characteristic findings of Sputum produced by coughing.

Causes

Causes of cough in children according to duration:

According to quality and sound of cough in children, the causes can be classified according to following chart.

Dry or Hacking or Nonproductive

Sinusitis, Tonsillitis, Pharyngitis, Allergic Rhinitis, GERD, Asthma, Environmental exposure to irritants(pollen, dust, mites, smokes), Post infectious cough.

Wet or productive cough

Cystic fibrosis, Bronchiectasis, Bronchiolitis, Tuberculosis, Rhinitis, Postnasal drip, Pneumonia, Emphysema, Acute bronchitis, Asthma

Causes of Cough based on Nature or quality and sound

Staccato or short repetitive cough

Chlamydia pneumonia

Whooping or paroxysmal violent or spasmodic cough

Pertussis

Barking cough

•Brassy barking: Croup, Tracheomalacia, Laryngitis, Tracheitis •Honking barking: Psychogenic cough , Tourette syndrome (habit cough)

Stridor

Viral Croup, Epiglottis, Bacterial tracheitis, Retropharyngeal and peritonsilar abscess

Burning cough

Bacterial Bronchitis, Irritants

Based on anatomical location the causes of cough in children can be demonstrated into following chart-

Nose and Paranasal sinuses

Rhinitis, Foreign Body, Sinusitis, Nasal polyp, ppHypertrophied inferior turbinate]]

Pharynx

Pharyngitis, Foreign Body, Irritants

Larynx

Laryngitis, Epiglottis, Tonsillitis, Laryngomalacia, Subglottic stenosis, Foreign body

Trachea and Bronchi

Tracheitis, Croup, Bronchiolitis, Bronchiectasis, Bronchitis, Cystic fibrosis

Causes based on anatomic location

Pulmonary parenchyma

Pneumonia, Tuberculosis, Environmental toxin, Respiratory distress syndrome, Aspiration syndrome, Hypersensitivity Pneumonitis, Connective tissue disease, Alveolar capillary dysplasia, Neuroendocrine cell hyperplasia of infancy, Medications, Mutations causing surfactant dysfunction, Emphysema

Pleura

Pleurisy, Pneumothorax, Hemothorax, Parapneumonic effusions, Pleural tuberculosis, Congenital hydrothorax and chylothorax

Mediastinum

Mediastinitis, Mediastinal Tuberculosis, Thymoma, Thymic hyperplasia, Thymic carcinoma, Neuroblastoma, Ganglioneuroma, Non Hodgkin lymphoma, Sarcoma, Mature teratoma, Endodermal sinus tumor, Hemangioma, Wilms tumor, Lymphangioma

Heart and blood vessels

Congenital heart disease, Valvular heart disease, Heart failure, Myocarditis, Cardiomyopathies, Wegener granulomatosis, Vasculitis, Arteriovenous malformation

External ear and Tympanic membrane

Otitis media and externa, Impaction of foreign body, wax, Myringitis

Esophagus

GERD, Tracheoesophageal Fistula

Differentiating Cough from other Diseases

Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
			Symptoms							Physical exam
			Onset	Duration	Productive cough	Hemoptysis	Weight loss	Fever	Dyspnea	Physical Examination	Lab findings	Imaging	PFT	Gold standard
Respiratory	Upper airway diseases	Epiglottitis	Abrupt or acute	12−24 hours	−	−	−	+	+	Ill appearing child in Tripod posture Inspiratory Stridor Hoarseness / Hot-potatoes or Muffled voice Drooling, Tachypnea, Tachycardia Cervical lymphadenopathy, Erythematous pharynx and larynx	Elevated white blood count in CBC Blood culture may show bacterial growth Epiglottal culture in intubated patients may show bacterial growth	Enlarge epiglottis (>8 mm), loss of vallecular air space and distended hypopharynx as known as 'Thumb print' sign on lateral neck X−ray may be helpful	Normal function	Direct visualization of erythematous and edematous epiglottis	Tripod posture Drooling Tenderness of the anterior part of the neck Etiology: Haemophilus influenzae
		Croup	Acute	3−5 days	+	−	−	+	+	Stridor Crackles	Leukopenia	Subglottic narrowing (steeple sign) in postero−anterior radiograph chest	Decresed tidal volume	Clinical diagnosis. Laboratory findings and imaging are not necessary for diagnosis	Barking cough Etiology: Parainfluenza virus type 1 (most common)
		Pertussis	Acute	Two weeks	+ Whooping sound	−	+	+	+	Clear chest	Polymerase chain reaction (PCR) shows Bordetella pertussis Serologic testing	Atelectasis may seen on chest imaging Lymphadenopathy	Normal function	Culture	Etiology: Bordetella pertussis Phases: Catarrhal, paroxysmal and convalescent
		Common Cold	Acute	3−10 days	+	−	−	+	−	Rales Wheezing	Bacterial culture is not indicated	Chest X−Ray in patients with signs of consolidation	Normal function	Clinical diagnosis	Conjunctival injection Nasal congestion
		Tonsilitis	Acute or Acute Recurrent, Chronic	Varies	+(Mucus from inflamed tissue)	−/+	−	+	Odynophagia, Tachypnea	Stridor Hoarseness of voice/ Dysphonia Cervical Lymphadenopathy	Rapid Antigen Detecting Test Throat Swab Culture EBV Heterophile Antibody Test Monospot Test Complete Blood Count	Chest X−Ray shows normal finding. USG may show Peritonsillar abscess.	Normal function	Rapid Antigen Detecting Test	Etiology: Rhinovirus, Adenovirus, Respiratory Syncitial Virus, Influenza Virus, Corona Virus, Group A streptococci
		Seasonal Influenza	Acute	Upper respiratory tract symptoms with fever peaking at three to four days, resolved by seven to ten days.	−	−	−	+(High grade)	+	Fussiness, Vomiting, Diarrhea, Myalgia, Focal wheezing, Rales, Tachypnea, Tachycardia, Retractions, Seizures	RT−PCR Virus culture Rapid Influenza diagonostic test Immunofluroscence-Direct or indirect Antibody testing	Reticular or reticulonodular opacities in chest X−Ray	Normal function	Clinical diagnosis	Etiology: A or B Influenza virus
		Sinusitis	Acute, Subacute, Chronic, recurrent	Acute: Less than 4 weeks Subacute: 4−12 weeks Chronic: More than 12 weeks Recurrent: 4 or more episodes or acute rhinosinusitis per year	+	−	−	+	+	Restlessness, Nasal Congestion, Post Nasal Drip, Facial Pain, Rhinorrhea	In complicated acute bacterial rhinosinusitis, endoscopic cultures or sinus aspirate is indicated Nasal culture may also be helpful	Air−fluid level, mucosal edema and bony erosion of sinus on CT MRI for distinguish the etiology	Normal function	Clinical diagnosis: Nasal congestion and Post Nasal drip , obstruction, and purulent rhinorrhea
Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
			Symptoms							Physical exam
			Onset	Duration	Productive cough	Hemoptysis	Weight loss	Fever	Dyspnea	Physical findings	Lab findings	Imaging	PFT	Gold standard
Respiratory	Lower airway	Asthma	Chronic	Years	+ Clear mucoid or yellow sputum	−	−	−	+	Wheezing (expiratory) Rales Rhonchi	Eosinophilia Total serum IgE in test for allergy may be helpful	Normal airways in chest X−ray CT if there any abnormality in chest X−Ray	FEV1/FVC ratio <70% and FEV1 >15% increase after 15 minutes of 2 puffs of beta 2 sympathomimetic drug After physical active FEV1 decreases by >15% After inhaled corticosteroid (ICS)FEV1 increased by >15%	Airflow limitation on spirometry	Family history Seasonal variation
		Bacterial Protracted Bonchitis	Chronic	Atleast four weeks	+(Purulent)	−	+	+/−	+	Wheezing Rhonchi	Sputum culture is not indicated PCR in bacterial infection may be helpful	Chest X−ray to exclude other diseases	FEV1 < 80%	Clinical diagnosis	Majority of cases are caused by Streptococci Pneumoniae, Hemophylous Influenza, Staphylococcus aureus
		Bronchiectasis	Chronic	Months to years	+ Mucopurulent sputum	+	−	−	+	Crackles Wheezing Shortness of breath Chest Pain	Complete blood count (CBC) Sweat Test, CFTR Gene analysis Ciliary motility test, Nitric Oxide Test, Ciliary strauctures, Genetic Testing IgG, IgM and IgA Sputum culture for fungi, bacteria and mycobacteria	Linear atelectasis and dilated airways in chest X−Ray Bronchoscopy, Upper GI Endoscopy, MRI/CT will provide information of other etiologies.	FEV1/FVC <70% Normal FVC Low levels of FEV1	CT of chest	Digital clubbing Recurrent pleurisy
		'Foreign body aspiration	Acute	Sudden Onset	+	+/-	−	+/-	+	Wheezing, Inspiratory or Biphasic Strioor Unilateral Decreased breath sounds Cyanosis	No specific tests	Hyperinflated lungs, atelectasis, and mediastinitis Shift in chest radiograph when the object is radio−opaque CT may be helpful	Not specific	Bronchoscopy	In children <1 year Organic materials in children
		Bronchiolitis	Acute	8−15 days	+	−	−	+	+	Rhinorrhoea Cyanosis, Hypoxia Intercostal and subcostal retraction Tachypnea Wheezing Crackles Grunting and Nasal Flaring	Complete blood count (CBC) may be helpful Urinalysis & urine culture ( in infants)	Chest X−Ray may be helpful	Normal function or obstructive changes (FEV1/FVC <70%) Air trapping in Lung volumes Reduced Diffusing capacity of carbon monoxide ( DLCO)	Clinical diagnosis	Etiology: Respiratory syncytial virus, Rhinovirus Children <2 years
		Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
					Symptoms							Physical exam
Onset	Duration				Productive cough	Hemoptysis	Weight loss	Fever	Dyspnea	Physical findings	Lab findings	Imaging	PFT	Gold standard
Respiratory	Lung Parenchyma	Pneumonia	Acute	Variable	+ Mucopurulent sputum	−	−	+	+	Crackles Egophony Decreased bronchial sounds	Leftward shift leukocytosis Blood culture in hospitalized patients Sputum culture in hospitalized patients	Consolidation, cavitation, and infiltrated interstitial in chest X−ray Anatomical changes observed in chest CT	Not specific	Infiltration observed in chest X−ray	Community−acquired pneumonia Healthcare−associated pneumonia
		Tuberculosis (TB)	Chronic	More than 2 or 3 weeks	+	+	+	+	+	Pleural effusion Crackles Whispered pectoriloquy Decreased fremitus Rhonchi	Sputum acid−fast bacilli (AFB) smear may be positive Mycobacterial culture may be positive Molecular testing may be helpful	Reactivation of TB is observed as infiltration in the upper lobe in chest X−Ray In patients with HIV, Tb is observed as lobar infiltration, adenopathy, lung mass named tuberculoma, small fibronodular lesions, and/or pleural effusion on chest X−Ray CT can detect early nodal process	Decreased FEV1 Reduced FVC	Isolation of Mycobacterium tuberculosis from some secretion	Etiology: Mycobacterium tuberculosis Complications: Pneumothorax, bronchiectasis, pulmonary destruction and chronic pulmonary aspergillosis
		Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
					Symptoms							Physical exam
					Onset	Duration	Productive cough	Hemoptysis	Weight loss	Fever	Dyspnea	Physical findings	Lab findings	Imaging	PFT	Gold standard
		Cardiovascular system	Cardiac Diease	Congenital Heart Disease	Acute or Chronic	Variable	+	−	+	−	+	Wheezing Hoarseness	Not specific	Upper endoscopy may be helpful Barium esophagram may be helpful	Normal function	PH testing
				Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
Symptoms							Physical exam
Onset	Duration	Productive cough	Hemoptysis	Weight loss	Fever	Dyspnea	Physical findings	Lab findings	Imaging	PFT	Gold standard
Ear	Earways Disease	Om/OE	Acute or Chronic	Variable	+	−	+	−	+	Wheezing Hoarseness	Not specific	Upper endoscopy may be helpful Barium esophagram may be helpful	Normal function	PH testing
		Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
					Symptoms							Physical exam
					Onset	Duration	Productive cough	Hemoptysis	Weight loss	Fever	Dyspnea	Physical findings	Lab findings	Imaging	PFT	Gold standard
		Others	Psychogenic	Tourrette or habitual	Acute or Chronic	Variable	+	−	+	−	+	Wheezing Hoarseness	Not specific	Upper endoscopy may be helpful Barium esophagram may be helpful	Normal function	PH testing
				Organ system		Diseases	Clinical manifestations								Diagnosis				Other features
							Symptoms							Physical exam
Onset	Duration						Productive cough	Hemoptysis	Weight loss	Fever	Dyspnea	Physical findings	Lab findings	Imaging	PFT	Gold standard
Gastrointestinal	Upper GI			GERD	Chronic	Variable	+	−	+	−	+	Wheezing Hoarseness	Not specific	Upper endoscopy may be helpful Barium esophagram may be helpful	Normal function	PH testing	−−

Epidemiology and Demographics

• Cough is one of the most common symptoms of children in outpatient department.
• Ninety percent of acute cough in children is resolved within three weeks. The prevalence of Chronic Cough in children is approximately 5% to 10% in USA according to American Academy of Pediatrics.

Age

• Cough is more commonly observed among children under 5 years of age.

Gender

• Boys are more commonly affected with cough than girls.

Race

• There are racial predilection for certain causes of Cough in children. Asthma is predominant in Blacks and American Indians or Alaska native while Cystic fibrosis, Wegener's granulomatosis are more frequently affecting Caucasians according to American Lung Association.

Risk Factors

• Common risk factors in the development of Cough in children are-
  • Preterm Birth and delivery by caesarian section.
  • Respiratory Distress Syndrome.
  • Congenital Heart Disease.
  • Age less than 1 year.
  • Maternal Influenza vaccination.
  • Malnutrition.
  • Secondary exposure to tobacco smoke.
  • Air pollutants, Mold, Inadequate ventilation.
  • Immunodeficiencies.
  • Daycare attendance.
  • History of Atopy.
  • Household pets.
  • Low socioeconomic status.

Natural History, Complications and Prognosis

• The majority of patients with acute cough have recovery within three weeks in 90% of cases. Some of cases are progressed to sub-acute and chronic phases. Chronic cough lasts more than eight weeks whereas recurrent cough can affect a child for more than two years with 1-2 weeks duration in each episodes.
• Early clinical features include frequent episodes of coughing, Runny nose, Sneezing, Low grade fever, Sore Throat, Night Sweats, Arching Back, Irritability, Failure to thrive, Fussiness, Chocking sensation(Foreign body impaction).
• If left untreated, Acute cough can cause following complication in children-
  • Otitis Media
  • Rash
  • vomiting
  • Diarrhea
  • Bronchitis
  • Pneumonia
• Chronic cough can progress to-
  • Inability to sleep
  • Bronchospasm
  • Dizziness/ Syncope
  • Pneumothorax
  • Pneumomediastinum
• Ribs fracture

• Prognosis is generally excellent in most of the causes of cough in children.

Diagnosis

Diagnostic Criteria

• The diagnosis of Causes of Cough is made after a detailed history, presenting complaints and physical examination and laboratory findings in some cases. Cough can be classified according to-
  • Duration.
  • Nature or quality of cough.
  • Etiology.
  • Anatomic location.
  • Grade.

A detailed history focusing on onset of disease, factors worsening the episodes, time of worsening, alleviating factors, amount work of breathing, presence of shortness of breathing, relation with vomiting, food intake, posture, presence of blood, systemic findings(fever, weight loss, hypotension, syncope, vertigo, dizziness, failure to thrive), episodes of chocking, household socioeconomic status, family history, Vaccination history, drug abuse and smoking in family members, atopy, Antenatal, perinatal, postnatal, Birth history, Developmental histort, feeding history. The following signs are alarming which need further emergent evaluation by the physician.

• Cyanosis or hypoxemia or hypoxia
• Respiratory distress
• Stridor
• Toxic appearance
• Weight loss

Symptoms

• Symptoms of Cough may include the following:

• Breathlessness and episodes of coughing
• Sneezing
• Fever
• Sore Throat
• Night Sweats
• Arching Back
• Irritability
• Failure to thrive
• Fussiness
• Chocking sensation(Foreign body impaction)
• Chills and Rigor
• Wheezing
• Headache, myalgia, fatigue

Physical Examination

• Patients with Cough usually restless, irritable, fussy. Children with severe respiratory distress usually are toxic and cyanotic in appearance. Presence of grunting, nasal flaring, Intercostal or subcostal retraction or Accessory muscle usage needs prompt evaluation.
• Physical examination may be remarkable for:

• Vital signs: Documentation according to patient's age-
  • Temperature
  • Heart rate
  • Respiratory rate
  • Blood pressure
  • Growth and developmental parameters: Weight, Height, Length, Occipito Frontal Circumferance
• General Appearence: Level of consciousness, Cyanosis, Distressed or ill appearing, Hydration and nutritional status.
• Skin: Turgor, color, texture, rashes or any other abnormal findings.
• Lymphatics: Lymphadenopathy, location, Number and size, consistency, adherence to underlying structures.
• Head: Size, shape, fontanelle, overlapping suture, scalp, hair.
• Eyes: Lacrimation, conjuntival injection, periorbital redness.
• Ears: Position of ears along with external auditory canal, tympanic membrane visualization.
• Nose: Any deviation of nasal septum, normal or hypertrophied inferior turbinates, nasal polyps and congesion, nasal discharge, tenderness over sinus point.
• Mouth and throat:
  • Lips: Color and congenital lesions.
  • Buccal mucosa: Hydration, Color, Presence of anomaly.
  • Tongue and teeth and gum: Developmental anomaly, Color, papllae.
  • Palate: Anomaly, arch.
  • Tonsils: Color, Size, Any membrane, calcification and Exudates.
  • Posterior pharyngeal wall: Color, appearence.
  • Gag reflex: Intact or not.
• Neck: Throid, Trachea position and examination, Any Cystic or nodular masses, presence of Nuchal Rigidity.
• Respiratory:
  • Inspection: Breathing pattern(Abdominal and periodic), Respiratory rate, Accessory muscle usage, Chest wall shape.
  • Auscultation: Breath sound symetry, vesicular, bronchial, rales, rhonchi, wheezes, stridor.
  • Percussion: Resonance, hyperresonance and dull.
  • Palpation: Trachea position, Tactile fremitus.
• Cardiovascular: Rhythm, murmur, any radiation of sound, pulse in both extremities.
• Gastrointestinal: Shape of abdomen, Umbilicus, Bowel sounds, Palpation to evaluate any organomegaly or masses. or rebound guarding.
• Musculoskeletal: Aching back, scoliosis, lordosis, kyphoscoliosis, swelling and tenderness in any muscles, joint, clubbing, edema, deformity of extremities, gait and posture, any sign for hip dysplasia.
• CNS: Primitive reflex, superficial and deep tendon reflex, strength and tone of muscles, cranial nerve examination.
• Genitourinary: Presence of external genitalia deformity , hydrocele, cryptoorchidism or hernia.

Laboratory Findings

• There are no specific laboratory findings associated with [disease name].

• A [positive/negative] [test name] is diagnostic of [disease name].
• An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
• Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].

Electrocardiogram

There are no ECG findings associated with [disease name].

OR

An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

X-ray

There are no x-ray findings associated with [disease name].

OR

An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with [disease name].

OR

Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

CT scan

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

There are no MRI findings associated with [disease name].

OR

[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Other Imaging Findings

There are no other imaging findings associated with [disease name].

OR

[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

• [Disease name] may also be diagnosed using [diagnostic study name].
• Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

• There is no treatment for [disease name]; the mainstay of therapy is supportive care.

• The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
• [Medical therapy 1] acts by [mechanism of action 1].
• Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

Surgery

• Surgery is the mainstay of therapy for [disease name].
• [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
• [Surgical procedure] can only be performed for patients with [disease stage] [disease name].

Prevention

• There are no primary preventive measures available for [disease name].

• Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

• Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].