Why this is concerning

1. Pulmonary TB - important to exclude because cough lasting about 3 weeks with fever is a typical trigger for TB evaluation, and close household contact raises concern for transmission.
2. COVID-19 or another viral respiratory infection, including a prolonged/post-viral course.
3. Community-acquired or atypical pneumonia.
4. Pertussis or other prolonged contagious respiratory infections, depending on cough pattern and local exposure.

Further approach

• Seek medical review the same day, and tell the clinic before arrival: “Both household members have fever and cough for 20 days; one has RA and may be immunosuppressed.”
• Until TB is excluded, both should wear a well-fitting mask, avoid close indoor contact with others, keep rooms ventilated, and avoid visiting vulnerable people.
• The patient should bring or photograph all RA medicines and any antibiotics/steroids already taken. Do not independently stop long-term steroid tablets, but speak to the rheumatology/medical team promptly about whether an immunosuppressive medicine should be temporarily held.

• Vitals, oxygen saturation, chest examination, and chest X-ray.
• Sputum testing if productive cough or TB is suspected: rapid molecular TB test/NAAT (such as Xpert MTB/RIF where available), AFB smear, and mycobacterial culture with drug-susceptibility testing.
• COVID-19 testing and tests for other respiratory pathogens as locally appropriate.
• CBC, renal/liver function and inflammatory markers as clinically indicated.
• Consider HIV testing if status is not known, because it changes TB risk and evaluation.
• If chest X-ray is unclear but clinical concern remains high, the clinician may consider CT chest or referral to respiratory/infectious disease/TB services.

Go to emergency care now if

• Shortness of breath, oxygen saturation below 94% if measured
• Chest pain, confusion, fainting, severe weakness/dehydration
• Coughing blood
• High or worsening fever, rapid deterioration
• Inability to take fluids or medicines

For symptom relief tonight, if cough is dry and distressing

• Dextromethorphan can be used short-term: 10-20 mg every 4 hours or 30 mg every 6-8 hours as needed, maximum 120 mg/day.
  • Do not use with an MAOI, and avoid or seek pharmacist/clinician advice if taking SSRIs/SNRIs, tramadol, linezolid, or other serotonergic drugs because of serotonin-toxicity risk.
  • Avoid alcohol and driving if drowsy.
• If the cough is mainly dry, tickling, warm fluids, honey at bedtime if not diabetic/uncontrolled diabetic, head elevation, and humidified air may help.
• If he is coughing up significant sputum, it is generally better not to strongly suppress the cough, as it helps clear secretions. Hydration is preferable.

Avoid for now

• Codeine-containing cough syrups, opioid syrups, or sedating combinations unless specifically prescribed after examination. They can cause sedation and respiratory depression, and can obscure worsening lung disease.
• Starting antibiotics, steroids, or inhalers empirically without examination.
• Nebulization or steam in close shared rooms if TB is being considered, because coughing/aerosol-generating procedures can increase exposure. Keep ventilation good and use masks around others.

Send for emergency assessment now if