Pertussis

Blok 27 – Agustus 2016

Objectives

1. Describe the 3 stages of pertussis and the

associated symptoms.
2. Compare commonly associated complications of
pertussis in young infants and older children.
3. List risk factors for severe disease in young infants.
4. Describe the appropriate management for
pertussis depending on age and severity of
disease.
“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
Infant with paroxysmal cough

 http://www.youtube.com/watch?v=wuvn-
vp5InE
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  Subconjunctival
emphysema bleed
 Pneumothorax  Petechiae
 Pneumomediastinum  Epistaxis
 Diaphragmatic  Hemoptysis
rupture  Umbilical/inguinal
hernias
 Rectal prolapse
 Failure to thrive
 Risk Factors for Severe Disease

 Retrospective descriptive study

 72 PICU cases; 1991-2003
 Inclusion: +Lab confirmation & Discharge
Diagnosis of Pertussis
 80% < 3 months of age; 40% < 6 weeks
 71% had a sick contact
 70% under-immunized

Surridge J, Segedin ER, Grant CC. “Pertussis Requiring Intensive Care.” Arch Dis Child
2007; 92: 970-975.
 Risk Factors for Severe Disease

Risk Factors for Death & Disability

Co-morbidity (RR 5.56; 95% CI1.5-8.15)
Elevated Lymphocyte Count (RR 5.75; 1.5-13)
Presenting w/ Seizures (RR 4.87; 1.18-8.34)
Presenting w/ Shock (RR 6.5; 1.89- 8.94)
Unvaccinated (8/9 subjects)
 56% had cough for < 8 days
 All 3 deaths had consolidative pneumonia

Surridge J, Segedin ER, Grant CC. “Pertussis Requiring Intensive Care.”

Arch Dis Child 2007; 92: 970-975
Differential Diagnosis
Pertussis-like syndrome
 Adenovirus  Foreign body aspiration
 Parainfluenza  GERD
 RSV
 Aspiration pneumonia
 Bordetella parapertussis
 Bordetella bronchiseptica  Asthma
 Chlamydia trachomatis
 Chlamydia pneumoniae
 Mycoplasma pneumoniae
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
Pertussis Case Definition

CID 2012:54 (15 June) • Cherry et al

 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 CDC guidelines (2005):
• < 1 month: Zithromax
• > 1 month: Zithromax, erythromycin or clarithromycin
• Bactrim is an alternative agent for infants > 2 months
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
 Age??
 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.
References

 Shah, B and Lucchesi M. Atlas of Pediatric Emergency Medicine. 2006. pp. 258-60.
 Zaoutis, L and Chiang V. Comprehensive Pediatric Hospital Medicine. 2007. pp. 388-93.
 Byrd, E and Ohl, C. “Pathogenesis and Epidemiology of Pertussis.” Up to Date. Last Updated
7/2009.
 Yeh, S and Mink, C. “Clinical Features and Diagnosis of Bordetella Pertussis in Young Infants
and Children.” Up to Date. Last updated 7/2009.
 Yeh, S. “Treatment and Prevention of Bordetella Pertussis in Young Infants and Children.” Up
to Date. Last updated 7/2009.
 Surridge J, Segedin ER, Grant CC. “Pertussis Requiring Intensive Care.” Arch Dis Child 2007;
92: 970-975
 Tozzi A, et al. “Diagnosis and Management of Pertussis.” CMAJ 2005; 172(4): 509-15.
 Greenberg D, Konig, C, and Heininger U. “Health Burden of Pertussis in Infants and Children.”
Pediatric Infectious Disease Journal 2005; 24: S39-S43.
 Stojanov S, Liese J, Belohradsky B. “Hospitalization and Complications in Children under 2
Years of Age with Bordetella Pertussis Infection.” Infection 2000; 28: 106-110.
 Images and Video from google.com and U tube.