Pediatrics, Pertussis

Author: Joseph J Bocka, MD, Director of Shelby Emergency Department, Attending Emergency Physician at Mansfield Hospital, Med Central Health System (Mansfield and Shelby, Ohio); Emergency Medical Service Medical Director for several services Contributor Information and Disclosures Updated: May 26, 2009

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Introduction
Background
In the prevaccination era, pertussis (ie, whooping cough) was a leading cause of infant death. The number of cases reported had decreased by more than 99% from the 1930s to the 1980s. However, because of many local outbreaks, the number cases reported in the United States increased by more than 2300% between 1976 and 2005, when the recent peak of 25,616 cases were reported.1 The disease is still a significant cause of morbidity and mortality in infants younger than 2 years. Pertussis should be included in the differential diagnosis of protracted cough with cyanosis or vomiting, persistent rhinorrhea, and marked lymphocytosis.

Pathophysiology
Bordetella pertussis is an aerobic, nonmotile, gram-negative coccobacillus that attaches to and multiplies on the respiratory epithelium, starting in the nasopharynx and ending primarily in the bronchi and bronchioles. Transmission is only human to human by means of exposure to aerosol droplets. The disease is highly contagious. Approximately 80-90% of susceptible individuals who are exposed develop the disease. Most cases occur in the late summer and early fall. A mucopurulosanguineous exudate forms in the respiratory tract. This exudate compromises the small airways (especially those of infants) and predisposes the affected individual to

the mortality rate for hospitalized patients in the United States and in Europe is about 1 per 500 cases (<0.000 deaths annually. Nearly 300. a rate that approaches the incidence in the prevaccination era. The World Health Organization (WHO) estimates that 294. Now.3-0.000 people per year) reported to the Centers for Disease Control and Prevention (CDC) in 2005 and 15.1% develop encephalopathy. The CDC reported 39 deaths from pertussis in 2005. about 10-25% of children younger than 4 years and 2-4% of all persons with pertussis secondarily develop bacterial pneumonia.6% of adults develop seizures. 12-32% of adults with prolonged (1-4 wk) cough have pertussis. International In England. Pertussis remains the most commonly reported vaccine-preventable disease in the United States in children younger than 5 years.4 per 1 million live births.632 (5.616 cases (8. About 0. encephalopathy. The lung parenchyma and bloodstream are not invaded. 32 (82%) occurred in infants younger than 3 months. The rate recently peaked to 25. dehydration.2 per 100. This rate decreased to a low in 1976. Today. blood culture results are negative. cyanosis. Cerebral hemorrhage occurs secondary to paroxysmal coughing. and Germany.000 deaths from pertussis in Africa are thought to have occurred over the last decade. which elevates the intracranial pressure (ICP). . Mortality/Morbidity The mortality rate had been greater than 50%.000 children died from pertussis worldwide in 2002.269 cases and 7518 deaths reported in the United States. This rate reached a low of 4 reported deaths in the United States in 1982 and has recently risen to an average of about 25 deaths annually. or cerebral hemorrhage.7 cases per 100. The overall infant mortality rate is 2. with 39 being reported in 2005. hypoxia.atelectasis.000) reported in 2006. and pneumonia.000 cases and nearly 10. Similar epidemic outbreaks have recently occurred in Sweden. which are believed to be a result of hypoxia or cerebral hemorrhage from the prolonged coughing spells. therefore. cough. Frequency United States The rate of pertussis peaked in the 1930s. The CDC estimates that 5-10% of all cases of pertussis are recognized and reported. Canada. This decline has resulted in thousands of cases reported recently. • • • About 90-95% of patients die from secondary pneumonia. In the prevaccination era.2% of those reported). when 1010 cases and 4 deaths occurred. the percentage of people vaccinated over the last 4 decades decreased to less than 30%. In reported studies. Approximately 1-2% of infants and 0. pertussis caused more than 270. with 265.

the growing majority of cases are now in those aged 10 years and older. o These paroxysms are less spontaneous than those observed in typical respiratory infections. whereas unvaccinated adults are most likely to have whooping and posttussive emesis. The catarrhal stage follows and lasts about 2-7 days. yet more than 90% of all deaths occur in this same age group. Because of the lack of maternal immunity transfer. o It is characterized by paroxysms of coughing.Sex Pertussis is more common in girls than in boys. which are provoked by feeding (in infants) and exertion. which leads to dehydration. and paroxysmal. These vaccinations help account for the more than 10-fold increase reported in those older than 18 years. . The asymptomatic incubation period lasts 7-10 days. Three injections of the cellular or acellular vaccine provide up to 12 years of protection. lasting about 1-8 weeks. However. catarrhal. Vaccinated adults usually develop only prolonged bronchitis without a whoop. o A substantial number of patients present with cyanosis and apneic spells. Findings include the following: o Minimal or no fever o Rhinorrhea o Anorexia o Mild but increasing cough The paroxysmal stage follows. 10-15 % of all cases occur in infants younger than 6 months. with more than 70% of cases reported in children younger than 5 years. o The inspiratory gasp or whoop eventually develops. The natural disease does not provide lifelong immunity as earlier thought. especially in those aged 6 months to 5 years. which has led to increased booster recommendations. Age • • • Pertussis occurs predominantly in those aged 3 months to 5 years. Clinical History • • • • • • Pertussis typically consists of 3 stages: incubation. o Hypoxia tends to be more severe than what the child's clinical appearance suggests. Infants younger than 6 months often have vomiting in association with the cough.

Risk factors include the following: o Nonvaccination in children o Contact with an infected person o Epidemic exposure o Pregnancy http://emedicine. Mild fever is common. Bordetella parapertussis and Bordetella bronchiseptica are less common than B pertussis and produce a clinical illness that is similar but milder to pertussis due to B pertussis. they wait a median of 3 weeks before seeking treatment. however.medscape. it can often be observed in unvaccinated adults. as can posttussive emesis. Hypoxia should be considered and assessed. On average. Dehydration is common on presentation.• About 12-32% of adults with persistent cough (>2 wk) have pertussis. Fever with a temperature of over 39°C is rare. Causes • • • The main causative organism is B pertussis. It is usually absent in those younger than 6 months and in most older vaccinated children and adults. Physical • • • • The classic inspiratory gasp or whoop primarily develops in those aged 6 months to 5 years.com/article/803186-overview .

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