Pertussis

Kate GoheenMarch 25, 2009Weill Cornell Medical College Class of 2010

Case Presentation

4 m.o. male with h/o Klinefelter Syndrome, bilateral hip dysplasia and club feet

CC: cough and difficulty breathing HPI: mild cough for one week, worsening, with one

10-second episode of coughing and cyanosis which prompted mother to come to ER

ER: mild respiratory distress, wheezing and retractions T 99.1 HR 152 RR 66 O2 sat 99%

Plan: admit to 4B for bronchiolitis

Hospital Course HD#1

Patient started on albuterol Q2

One witnessed episode of coughing and cyanosis <10 seconds

Nebs changed to racemic epinephrine and levalbuterol

DFA and cx sent for pertussis

Started on azithromycin

Hospital Course Cont’d

HD#2 Febrile to 101.3 CXR showed RLL infiltrate, WBC 15.1 (N32%,

L59%) Cefuroxime added Levalbuterol maintained Q6

HD#4 DFA and cultures negative Discharged to home on cefuroxime and

azithromycin

What is Pertussis?

Whooping cough, “The Cough of 100 Days”

Infants are at high risk of complications

Preventing Tetanus, Diphtheria, and Pertussis Among Adults: Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine. Kretsinger, Katrina et al. MMWR Recommendations and Reports December 15, 2006 / 55(RR17);1-33.

Infants accounted for 92% of US pertussis deaths in 2000-2004.

Infant Pertussis Deaths, 2000-2004

76

142

0-1 mo

2-3 mo

4-6 mos

Annual Reported of Cases of Pertussis in the US, 1922-2003

Pertussis- Not Just for Kids. Hewlett, Erik and Edwards, Kathryn. NEJM 352;12 March 24, 2005, p. 1215-1224.

Spread of Pertussis: Then vs. Now

Increased awareness and reporting Better tests Waning immunity in adults

Why is the Incidence of Pertussis Increasing?

Immunized kids also get pertussis

DT DTaP

Cough (days) 61* 29-33

Apnea (%) 84.5* 36-47

Cyanosis (%) 64.9* 21-31

Vomiting (%) 85.6* 56-58

Clinical presentation of pertussis in unvaccinated and vaccinated children in the first six years of life. AU Tozzi AE; Rava L; Ciofi degli Atti ML; Salmaso S SO. Pediatrics 2003 Nov;112(5):1069-75.  

*P < .001

Clinical Presentation of Pertussis by Vaccine Group in Infants 6-24 Months Old

Pertussis is milder in immunized adults and adolescents

Persistent cough can be the only symptom Whooping in 20-40% Post-tussive emesis in

about half “Scratchy throat” in 33% Sweating episodes in 40-

50% pts over 30 y.o.

13-32% of adults with cough >6 days have serologic evidence of B. pertussis infection

Preventing Tetanus, Diphtheria, and Pertussis Among Adults: Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine. Kretsinger, Katrina et al. MMWR Recommendations and Reports December 15, 2006 / 55(RR17);1-33.

Diagnosis and Treatment

Pertussis can only be recovered in first 3-4 weeks of illness, very hard to culture

Do culture and PCR Tx: 5 days of

azithromycin for patients and contacts

Centers for Disease Control and Prevention. Recommended antimicrobial agents for the treatment and postexposure prophylaxis of pertussis. 2005 CDC guidelines. MMWR 2005; 54:10.

Vaccine Schedule: Expanded to Adults!

DTaP 2, 4, 6 months 15-18 months 4-6 years

Tdap 11-12 years One dose between 19-

64 (instead of Td) Any adult in contact

with infant <1 y.o.

Conclusions

Pertussis is still around! Infants have high

morbidity and mortality Suspect pertussis in

any patient with a prolonged cough, even if vaccinated

Encourage parents and grandparents to get Tdap boosters

Thank you!

Questions? Comments?