In clinical practice, patients who present with cough as the sole or primary symptom lasting >8 weeks and exhibit no marked abnormalities on chest radiographs are often diagnosed with chronic cough (1,2). Chronic cough affects ~10% of the general population and accounts for over one-third of visits to respiratory outpatient clinics in China (3). Epidemiological studies of the Chinese population report a prevalence of chronic cough ranging from 2.0 to 28.3% (3), with the majority of cases occurring in individuals aged 30-40 years and a nearly equal sex distribution (4).

Chronic cough has diverse etiologies, with common causes including cough variant asthma (CVA), upper airway cough syndrome (UACS), eosinophilic bronchitis (EB), gastroesophageal reflux cough (GERC) and atopic cough. These conditions account for 70-95% of cases, with multicenter data identifying CVA as the most prevalent, responsible for 32.6% of cases in China (5,6). The prevalence of GERC is rising, likely due to changes in diet and lifestyle. Despite thorough evaluation, 8.4% of chronic cough cases remain unexplained (7). Reported risk factors for chronic cough include air pollution, seasonal changes, dietary triggers, occupational exposure, allergens, smoking, female sex, advanced age, obesity and certain medications (8).

CVA typically responds well to anti-asthmatic therapy, including inhaled corticosteroids (ICSs) and leukotriene receptor antagonists. Early diagnosis and treatment are crucial, as untreated CVA may progress to classic asthma. Diagnosis relies on objective evidence of airway hyperresponsiveness (AHR), such as that obtained by bronchial provocation testing (9). Gastroesophageal reflux disease (GERD) and CVA frequently coexist and may exacerbate each other: Reflux can aggravate AHR, while persistent coughing may increase intra-abdominal pressure, promoting reflux (10,11). This bidirectional relationship is supported by studies showing that gastric contents can induce bronchoconstriction via vagally-mediated reflexes and microaspiration, thereby contributing to airway inflammation and hyperresponsiveness (12,13). Conversely, coughing in CVA may increase the frequency of transient lower esophageal sphincter relaxations, facilitating reflux episodes and establishing a cycle of mutual exacerbation (14). This interrelationship highlights the importance of a combined therapeutic approach. In clinical practice, the management of GERC typically involves lifestyle modifications, acid suppression and prokinetic therapy, with surgical intervention considered in refractory cases (10).

Given the multifactorial nature of chronic cough and its often prolonged course, effective management requires accurate diagnosis and individualized treatment plans (15,16). However, misdiagnosis and inadequate treatment remain common in primary care, largely due to limited diagnostic tools and clinical experience. The present report describes a case of CVA complicated by GERC, manifesting as persistent dry cough. The case underscores the importance of the flexible application of clinical guidelines in primary care and highlights that timely referral to specialized centers is necessary when patients have an unclear diagnosis or poor response to empirical therapy. Enhancing diagnostic and therapeutic capacity in primary care is essential for improving outcomes in patients with chronic cough.

The present case report describes a young female patient with a chronic, non-productive cough and an allergic predisposition, ultimately diagnosed with CVA complicated by subclinical GERD. The patient initially presented with features typical of CVA, including a persistent, dry, irritating cough, and no evident radiographic or ventilatory abnormalities. Elevated FeNO levels and a positive bronchial provocation test supported the CVA diagnosis, while fiberoptic bronchoscopy ruled out other possible etiologies such as bronchial tuberculosis, foreign bodies or airway tumors.

Despite the initiation of standard CVA treatment, including an ICS, a leukotriene receptor antagonist and a cough suppressant, the patient's response was limited. Notably, she also reported symptoms suggestive of gastroesophageal reflux, and the laryngoscopy findings were consistent with reflux laryngitis. These observations prompted a shift in diagnostic focus, highlighting GERD as a potential exacerbating factor. Following a 10-day course of anti-reflux therapy with omeprazole and domperidone, her symptoms significantly improved, suggesting an important role of GERD in the clinical presentation.

The delayed recognition of GERD was attributable to the absence of classic symptoms such as heartburn or regurgitation. The initial therapy was focused solely on CVA; however, GERD-induced airway hypersensitivity and inflammation likely compromised asthma control. Additionally, the typically delayed onset of extra-esophageal symptom relief with the proton pump inhibitor (PPI) omeprazole may have masked the early benefits of anti-reflux therapy. Ultimately, a combined pathophysiology-based approach targeting both CVA and GERD was necessary to achieve symptom resolution.

The present case exemplifies the diagnostic complexity of overlapping CVA and GERD, particularly when reflux presents atypically. While the initial focus on CVA was reasonable given the patient's allergic history and positive bronchial challenge test, the limited response prompted a broader evaluation. Gastroenterology consultation was prompted by the laryngoscopic findings and clinical suspicion, and confirmed subclinical GERD. Interdisciplinary collaboration subsequently enabled a refined diagnostic approach and the initiation of tailored anti-reflux therapy which, in combination with asthma-directed treatment, led to progressive and ultimately sustained symptom relief.

The roles of the respiratory and gastroenterology departments were clearly delineated throughout the care of the patient. The respiratory team conducted the initial assessment, pulmonary function testing, FeNO measurement and bronchial provocation testing. Following limited response to initial treatment, the gastroenterology team was consulted to assess potential reflux pathology, interpret laryngoscopy results, and initiate acid-suppressive and prokinetic therapy. Although no formal joint consultations were conducted, close communication between the two departments ensured coordinated management and appropriate follow-up planning.

Importantly, the present case highlights that GERD should be considered in patients with chronic cough who are unresponsive to conventional asthma therapies, even in the absence of typical gastrointestinal symptoms. While GERD and CVA are each well-established causes of chronic cough, their coexistence is relatively common and clinically relevant. However, atypical presentations, such as chronic cough in young female patients without heartburn or regurgitation (17,18), may delay diagnosis and treatment, particularly in primary care settings. Extra-esophageal manifestations such as chronic cough occur in up to 30-40% of patients with GERD and are frequently underdiagnosed (18). Unlike most reports that address CVA and GERD separately, the present case demonstrates the diagnostic value of recognizing their overlap and the therapeutic efficacy of a sequential, physiology-guided dual treatment strategy.

Another important aspect is the role of multidisciplinary collaboration. Coordinated care between respiratory and gastrointestinal specialists enabled a tailored treatment strategy in the present case, with monitoring for potential long-term effects, such as bone loss associated with ICS and PPI use. This underscores the value of integrated, patient-centered care in managing complex overlapping conditions.

The successful use of telemedicine played a crucial role in the follow-up of the patient. Remote monitoring through structured questionnaires and video consultations facilitated continuity of care, reinforced adherence and enabled timely interventions, which are particularly beneficial in settings with limited access to in-person services.

The present case also highlights the importance of clinical reasoning and flexible diagnostic strategies in resource-limited environments. While advanced diagnostic tools such as 24-h pH monitoring or induced sputum eosinophil counts were unavailable, clinical assessment, FeNO measurements and laryngoscopic findings effectively guided the diagnosis. The achievement of a favorable response further validated this pragmatic approach.

However, several limitations must be acknowledged. A major constraint was the lack of objective pre- and post-treatment comparison data, including follow-up FeNO levels, spirometry parameters (e.g., FEV₁) and standardized cough scores. This was primarily due to the patient's early discharge, which was prompted by significant symptom relief, as well as a need to return to work in another city. As a result, follow-up was conducted remotely via telephone, limiting the ability of the medical team to quantify the treatment response using physiological measures. Additionally, although initial laboratory tests, such as eosinophil counts and Mycoplasma pneumoniae antibody titers, supported the diagnostic process, serial monitoring of these indicators was not conducted, which restricts the ability to associate treatment effects with biomarker trends. These limitations reflect the challenges of conducting detailed longitudinal assessments in resource-limited or remote follow-up settings.

However, the present case highlights several important considerations for clinical practice. For primary care physicians, it emphasizes the importance of considering GERD as a potential contributor to chronic cough, even in the absence of classical gastrointestinal symptoms, particularly when patients do not respond to standard asthma treatments. For pulmonologists, the case supports the adoption of a pathophysiology-based diagnostic and therapeutic approach for the management of complex or refractory cases of chronic cough. For multidisciplinary teams, it illustrates the practical benefits of shared decision-making and role-specific expertise. Furthermore, at the healthcare system level, it underscores the value of integrating telemedicine into the follow-up and fostering multidisciplinary collaboration to improve the diagnosis, treatment and long-term management of overlapping chronic conditions.

In conclusion, while CVA and GERD are each common conditions individually, the novelty of the present case lies in their atypical concurrent presentation in a young female with no classic reflux symptoms. In addition, the case highlights the dynamic diagnostic shift and effective cross-specialty collaboration that led to symptom resolution without invasive testing. This reinforces the importance of a systematic, individualized approach when evaluating chronic cough, which is a frequently encountered but diagnostically challenging condition in clinical practice.