Updated: 1/1/2019

Pertussis

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Topic
Snapshot
  • A 40-year-old man presents to the primary care physician after 3 weeks of a dry cough. He reports that he occasionally vomits after an episode of coughing and he hears “whoops” during some episodes. His childhood immunization history is incomplete, and the patient states not having had any immunizations in the past 20 years. A special nasopharyngeal swab is sent for analysis and antibiotics are given.
Introduction
  • Classification
    • Bordetella pertussis
      • a gram - aerobic coccobacilli
    • transmission
      • respiratory droplets
  • Epidemiology
    • demographics
      • infants are especially at risk
        • < 6 months of age
        • too young to be vaccinated
      • unvaccinated children
    • risk factors
      • exposure to infected people
      • incomplete vaccination
      • HIV exposure
  • Pathogenesis
    • bacteria colonizes mucosal surface
    • pertussis toxin binds to and activates adenylate cyclase by inhibiting Gi
      • impairs phagocytosis, allowing the bacteria to survive
    • tracheal cytotoxin
      • impairs cilia, preventing normal clearance of respiratory secretions
    • low lung volume at the beginning of inspiration causes strong inspiration and inspiratory “whoop”
  • Associated conditions
    • whooping cough
    • 100-day cough
  • Prevention
    • DTaP vaccine
      • vaccine against diphtheria, tetanus, and pertussis
      • acellular pertussis vaccine
      • 5 doses before school-age, completed by 4-6 years of age
    • Tdap vaccine
      • booster vaccine at 11-12 years of age
      • should also be given to pregnant mothers and those around them
  • Prognosis
    • can be fatal in infants
Presentation
  • Symptoms
    • catarrhal stage (first)
      • low-grade fevers
      • coryza
    • paroxysmal stage (second)
      • dry cough and whoop
      • post-tussive vomiting
    • convalescent stage (third)
      • recovery
  • Physical exam
    • whooping cough in children
      • dry cough on expiration
      • “whoop” on inspiration
    • 100-day cough in adults
      • post-tussive vomiting
      • paroxysmal cough
Studies
  • Labs
    • culture in
      • Bordet-Gengou agar
      • Regan Lowe medium
    • polymerase chain reaction
    • serology
    • requires nasopharyngeal secretions on a special swab, as the bacteria will not grow on cotton
  • Making the diagnosis
    • based on clinical presentation and laboratory studies
Differential
  • Mycoplasma pneumonia
    • distinguishing factor
      • also presents with a dry cough, but no whooping cough and no posttussive vomiting
Treatment
  • Management approach
    • infected patients should avoid exposure to vulnerable populations
    • exposed patients should still be treated
  • Medical
    • macrolides
      • indication
        • first-line therapy
      • drugs
        • azithromycin 
        • clarithromycin
        • erythromycin
    • trimethoprim-sulfamethoxazole
      • indication
        • allergies to macrolides
Complications
  • Pneumonia
  • Failure to thrive
  • Death
    • especially in young infants
  • Apnea
    • especially in young infants

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Questions (3)
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(M2.ID.17.4838) A 12-year-old female presents to the emergency department for cough. Her mother reports that the child has had rhinorrhea and cough for almost three weeks. The cough seems to be getting worse and often wakes the patient up from sleep. The patient has also had several episodes of post-tussive emesis. The patient’s mother has been treating the patient with oral antihistamines for presumed allergies, and an albuterol inhaler borrowed from the patient’s older brother. The patient has not been seen by a pediatrician for several years and her mother is unsure of her vaccination history. The patient’s temperature is 98.8°F (37.1°C), blood pressure is 96/71 mmHg, pulse is 90/min, and respirations are 14/min. On physical exam, the patient appears well. Her lungs are clear to auscultation bilaterally. The patient has the physical exam finding seen in Figure A. Which of the following is the best next step in management?

QID: 109494
FIGURES:
1

Azithromycin for patient and close contacts

54%

(32/59)

2

Intravenous dexamethasone and nebulized epinephrine

3%

(2/59)

3

Intravenous ceftriaxone

0%

(0/59)

4

Oral dexamethasone and nebulized albuterol

3%

(2/59)

5

Supportive care only

37%

(22/59)

M 7 D

Select Answer to see Preferred Response

(M2.ID.14.28) An 89-year-old woman presents to clinic complaining of a cough. She reports that she has never had a cough like this before. She takes a deep breath and then coughs multiple times, sometimes so much that she vomits. When she tries to catch her breath after a coughing spell, she has difficulty. She reports the cough has persisted for 3 weeks and usually comes in fits. Vital signs are stable. Physical examination is benign. You send cultures and a PCR of her secretions, both of which come back positive for the organism you had suspected. You tell her to stay away from her grandchildren because her illness may be fatal in infants. You also start her on medication. The illness affecting this patient would be best treated by a class of antibiotics...

QID: 105426
1

that may prolong the QT interval

37%

(30/81)

2

that may cause tooth discoloration and inhibit bone growth in children

19%

(15/81)

3

that is known to cause nephrotoxicity and ototoxicity

31%

(25/81)

4

that may cause gray baby syndrome in premature infants

5%

(4/81)

5

that may cause a disulfiram like reaction when taken with alcohol

7%

(6/81)

M 7 E

Select Answer to see Preferred Response

Evidence (2)
EXPERT COMMENTS (4)
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