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Azithromycin for patient and close contacts
56%
37/66
Intravenous dexamethasone and nebulized epinephrine
3%
2/66
Intravenous ceftriaxone
0%
0/66
Oral dexamethasone and nebulized albuterol
Supportive care only
36%
24/66
Select Answer to see Preferred Response
This patient presents with a history of incomplete childhood immunizations, rhinorrhea, cough, post-tussive emesis, and subconjunctival hemorrhage, which suggests a diagnosis of infection with Bordetella pertussis. Infection with Bordetella pertussis classically occurs in three phases: the catarrhal phase, the paroxysmal phase, and the convalescent phase. In the catarrhal phase (1-2 weeks), patients typically have non-specific symptoms of an upper respiratory infection, and in the paroxysmal phase (2-6 weeks), patients present with periodic bouts of coughing with the characteristic “whoop” on inspiration. Immunization from childhood vaccinations wanes in adolescence, when patients should receive a booster. Treatment involves a macrolide antibiotic such as azithromycin or erythromycin for the patient, as well as all close contacts. Figure A demonstrates the finding of a subconjunctival hemorrhage, which is commonly found in infection with Bordetella pertussis due to forceful coughing. Incorrect Answers: Answer 2: Dexamethasone and nebulized epinephrine is the initial treatment of moderate to severe croup. Croup typically presents with fever and inspiratory stridor, which are not present in this patient. Answer 3: Intravenous ceftriaxone is appropriate treatment for epiglottitis. Epiglottitis typically presents with drooling and tripod positioning to open the airway. This patient is in no acute distress. Answer 4: Oral dexamethasone and nebulized albuterol would be appropriate treatment of an asthma exacerbation. While asthma can present with coughing that is worse at night, this patient has no history of asthma, and her symptoms have not improved with home administration of albuterol. Answer 5: Supportive care would be appropriate for a viral upper respiratory infection such as adenovirus. Infection with adenovirus does not typically cause paroxysms of forceful coughing. Bullet Summary: Infection with Bordetella pertussis should be treated with macrolide antibiotics such as azithromycin for the patient as well as any close contacts.
4.1
(7)
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