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PERTUSSIS

WHOOPING COUGH

Pertussis= means violent cough


Case Definition (WHO):
Cough

lasting at least 2 weeks with one of the


following criteria:

Paroxysms of coughing
Inspiratory whooping
Post-tussive vomiting without apparent cause

PERTUSSIS
Description (WHO): Pertussis, or
whooping cough, is a disease of the
respiratory tract caused by bacteria
that live in the mouth, nose, and throat.
Many children who contract pertussis
have coughing spells that last four to
eight weeks. The disease is most
dangerous in infants. Pertussis spreads
very easily from child to child in
droplets produced by coughing or
sneezing

EPIDEMIOLOGY

Currently 20-40 million cases yearly world


wide. 90% of cases in third world countries
Case fatality rate 0.2% in U.S.
84%

are less than 6 months old.

Incidence declined from 1940 to 1970 in


post-vaccine era.
Incidence has tripled from 2001 to 2005.

PERTUSSIS EPIDEMIC

Increasing incidence of pertussis in the


last 20 years
Increased circulation of B. pertussis
Waning vaccine-induced immunity in
adolescents and adults
Decreased use of the pertussis vaccine
(in some developed countries outside
the United States)
Heightened awareness of pertussis
among health-care providers
Increased use of PCR testing for
diagnosis
Increased public health reporting

PATHOPHYSIOLOGY

B. pertussis is transmitted by aerosolization of droplets


B. pertussis attaches to the respiratory cilia and produces toxins.

Toxins act by:

Paralysis of cilia
Causing inflammation of the respiratory tract
Impairing clearance of mucous
Increasing insulin secretion
Inhibiting phagocytic function
Induction of lymphocytosis by inhibiting migration from blood stream

Filamentous hemagglutinin, pertactin and agglutinogens help w/


attachment to epithelium
Adenylate cyclase impairs phagocytic function
Tracheal toxin causes ciliary stasis

CLINICAL FEATURES

Incubation period: 7 10 days


3 Stages
Catarrhal:

1-3 wks
Paroxysmal: 2-4 wks
Convalescent: 1-2 wks

CATARRHAL STAGE

Symptoms:
Low-grade

fever

Rhinorrhea
Mild

cough
Mild conjunctival injection

Caregivers usually do not seek medical


attention

CMAJ, 2005

PAROXYSMAL STAGE

Paroxysmal cough
Short,

expiratory bursts-- followed by a


prolonged inspiratory gasp (whoop)

Whoop may be absent in young infants

May

be more frequent at night


Possible cyanosis and apnea in young infants
Ends in episode of vomiting

Patient appears well in between


paroxysms
Petechiae, subconjunctival hemmorhage

PAROXYSMAL STAGE: NATURAL


COURSE

Coughing spells increase in


frequency in the first 1-2
weeks
Then same level for another 2
weeks.
Gradually then decrease.
This stage may last 6-10
weeks.

CONVALESCENT STAGE

Waning of symptoms over several weeks


Paroxysms may recur with subsequent
respiratory infections.
Can

occur for months after initial infection.

COMPLICATIONS

Life Threatening complications can occur


with pertussis, especially in young infants.
Categories:
Neurological
Pulmonary
Infectious
Pressure-

related due to forceful cough

NEUROLOGIC
COMPLICATIONS

Seizures (3%)
Encephalopathy
Cerebral hemmorhage

INFECTIOUS
COMPLICATIONS

Apnea (12%)
Pertussis pneumonia(6%)
Bacterial superinfected
pneumonia (6%)
May include aspiration
pneumonia
Leading cause of death
Otitis Media
Viral Co-Infections

PULMONARY
COMPLICATIONS

Pulmonary Hypertension
Patients

present in shock.
Usually require mechanical
ventilation and possibly
ECMO

Atelectasis
Due

to mucous plugs

COUGH-INDUCED
COMPLICATIONS

Subcutaneous
emphysema
Pneumothorax
Pneumomediastinum
Diaphragmatic
rupture

Subconjunctival bleed
Petechiae
Epistaxis
Hemoptysis
Umbilical/inguinal
hernias
Rectal prolapse
Failure to thrive

DIFFERENTIAL DIAGNOSIS

Trankeobronkitis
bronkiolitis

DIAGNOSIS

Gold Standard= Culture


Highest

yield early in illness (1st 2 weeks)


Must culture nasopharynx w/ Dacron or calcium
alginate swabs.
Should be plated in timely manner
Takes 10-14 days to grow
Results obscured by prior antibiotics or
vaccination

Bordatella PCR testing- rapid, sensitive &


specific
Direct immunofluorescence assay (DFA)low specificity, variable sensitivity

CLASSIC FINDINGS UPON


DIAGNOSTIC EVALUATION

CBC shows leukocytosis with lymphocytic


predominance
Significant

lymphocytosis (>95th percentile) is


present in 1/3 of patients

Chest X-ray with normal findings or shaggy


perihilar infiltrates or diffuse infiltrates

INFECTIOUS
PRECAUTIONS

Respiratory droplet
precautions for 5 days
after initiation of antibiotic
therapy.
Contact precautions due to
nasopharyngeal secretions

TREATMENT

Macrolide therapy can shorten course if


started early in catarrhal stage. If started
later, will still decrease infectivity and
spread of disease.
According to Panduan Praktek Klinik
RSMH:
<

1 month: Azitromycin, Eritromycin


> 1- 5 month: Azitromycin, Erythromycin or
Clarithromycin
> 6 month : Azitromycin, Eritromycin,
Clarithomycin
TMP-SMZ is an alternative agent for infants > 2

POST-EXPOSURE

Highly contagious! 90% of nonimmune


household contacts acquire disease.
All household contacts should receive
prophylaxis regardless of age or
immunization status.
Dose

of macrolide is same as treatment dose.

Pertussis vaccine should also be given to


unimmunized or incompletely immunized
individuals.

ADMISSION CRITERIA

Feeding difficulties
Paroxysms associated with apnea or
cyanosis
Hypoxia
Respiratory distress
Other complications (seizures, respiratory
failure, etc.)

DISCHARGE CRITERIA

Adequate PO intake to maintain hydration


and weight gain.
No hypoxia or bradycardia w/ paroxysms
Reliable care takers and follow up.

PREVENTABLE DISEASE

The vaccine mediated


immunity lasts 3-5 years after
vaccination.
Adolescents and adults were
becoming reservoir for
infection.
Maternal pertussis is risk
factor for disease in infants.
In 2005, FDA licensed Tdap.

THANK YOU