Dear Editor,
Cough is the body’s natural response to airway irritation, which may not necessarily indicate an adverse condition. However, it belongs under the category of chronic cough if it lasts more than four weeks in children and is a common complaint for patients seeking medical attention. Several medical conditions may cause a chronic cough in children, including asthma, gastroesophageal reflux disease, and environmental exposure (e.g., tobacco smoking).
Patients often suffer from physical complaints. Suffering may have psychological aspects, and psychological distress is central in some patients. Somatic symptom disorder (SSD) is described as persistent (> six months) and somatic complaints with functional impairment, accompanied by excessive and disproportionate health-related thoughts, feelings, and behaviors regarding the symptoms (Table 1) (1). The complaints are real, but medical conditions cannot be explained them.
Somatic cough syndrome is a type of SSD that causes a chronic cough with unexplained medical etiology. Its prevalence rate needs to be better documented, but cases mainly occur in children and adolescents between 8 and 14 years. Somatic cough syndrome is usually diagnosed after a comprehensive search for organic reasons. The classic presentation is a harsh, barking, repetitive cough that emerges several times per minute for hours. There is no expectoration, history of breath shortness, fatigue, or voice quality changes. Moreover, patients often experience either an absence of nocturnal symptoms or a significant reduction in symptoms once they fall asleep (2,3). However, the presence/absence of nocturnal cough and barking/honking quality should not be used to diagnose or exclude somatic cough syndrome, according to the American College of Chest Physicians (ACCP) (2,3).
Another medical condition that may lead to chronic cough has emerged recently: the coronavirus disease 2019 (COVID-19). COVID-19 has infected people of any age and has caused mild to severe symptoms, including fever, headache, cough, shortness of breath, myalgia, and loss of taste or smell. Children infected with COVID-19 were also usually asymptomatic, and their rates of hospitalization and death were lower than those of adults. Additionally, some people infected with the virus have experienced symptoms that persist for a few weeks or months after the onset of the illness, a phenomenon known as “long COVID.” Long COVID can present in anyone infected with the virus, regardless of age or severity of symptoms, and includes a wide range of ongoing symptoms, such as fatigue, insomnia, prolonged cough, chest pain, and cognitive dysfunction (4). Several factors have been identified as contributing factors to long COVID, including older age (> ten years), female gender, and multisystem inflammatory syndrome. There is no specific diagnostic test for long COVID, and clinical investigations toward diagnosis (e.g., routine blood tests and chest radiography) were occasionally inconclusive.
In summary, the diagnosis of chronic cough has become even more complex with COVID-19 pandemic. Somatic coughing and long COVID are two conditions that should be considered in the differential diagnosis of chronic cough. Despite some similarities, there are apparent differences between long COVID and somatic coughing. Firstly, long COVID often involves multisystemic symptoms (e.g., shortness of breath, heart palpitation, and joint pain) that persist after a COVID-19 infection. In contrast, somatic cough syndrome involves a single symptom¾a cough that can be suppressed through distraction or suggestion. Secondly, somatic coughing is generally related to specific triggers, such as psychological distress. Therefore, COVID-19 pandemic can predispose to somatic cough as a distressing factor. Thirdly, somatic coughing is more common in children and adolescents, unlike long COVID. Lastly, treatment for somatic cough is focused on addressing the underlying causes, including suggestion therapy, reassurance, and psychotropics to manage stress or anxiety (5). However, no specific treatment is available for long COVID, and treatment mainly focuses on alleviating the symptoms.
Somatic coughing is crucial due to its adverse impacts on children (e.g., decreased ability to play, disturbing relationships with peers, and decreased school performance). Therefore, early diagnosing is critical, and it is essential to keep in mind somatic cough syndrome when approaching children with chronic cough, especially during the “long COVID” era.