Pertussis

Kate Goheen March 25, 2009 Weill 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

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

Infant Pertussis Deaths, 2000-2004 14 2

0-1 mo 2-3 mo 4-6 mos

76

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.

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

Why is the Incidence of Pertussis Increasing?

 Increased awareness and reporting  Better tests  Waning immunity in adults

Immunized kids also get pertussis

Clinical Presentation of Pertussis by Vaccine Group in Infants 6-24 Months Old DT Cough (days) 61* DTaP 29-33 Apnea (%) Cyanosis (%) 84.5* 64.9* 36-47 21-31 Vomiting (%) 85.6* 56-58 *

P

< .001 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.

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?