A Case of a Family With Cough - Pertussis Is Back

August 2009

By Mitchell B. Cordover, M.D.
ACEP News Contributing Writer

This article was underwritten by an unrestricted educational grant by Sanofi Pastuer, ACEP’s Official Wellness Supporter.

A previously healthy 24-year-old African American female came to the emergency department complaining of persistent cough and pain in her right lateral chest. The pain started suddenly during a bout of hard coughing that had become chronic. The pain increased with deep inspiration, cough, or certain movements. She had experienced "a little cold" with sneezing, mild occasional cough, and a low-grade fever about 3 weeks prior. But after a week, the cough became worse and was especially bad at night. She couldn't sleep and felt exhausted.

She had been seen by her private doctor and again at another emergency department and had been diagnosed with "asthmatic bronchitis." But the inhaler she was prescribed did not help the cough, and she had never suffered from asthma before. She had been prescribed levofloxacin by her doctor along with a steroid dose pack, but he stopped the medication when she called him about heel pain.

Physical exam was unremarkable except for a persistent cough. There were no wheezes, rales, or rhonchi. Her white blood cell count was 16.5k with 60% lymphocytes. Chest x-ray showed moderate hyperinflation but no acute pathology. Rib films failed to demonstrate a fracture. There was motion artifact on the film because she could not keep from coughing. Influenza swab was negative.

The patient admitted that she went to the emergency department that day in part because her two young children were being seen in the pediatric area. Both children had caught her cold, but the baby had developed a fever of 101° F and was now vomiting when she coughed. Both the baby and her brother were coughing so hard "that their faces turned blue," and their pediatrician had referred them to the emergency department to rule out pneumonia. It had just gotten bad during the previous 24 hours. She said she had not had her children immunized for fear of possible side effects.

Mini swabs were done on the patient's anterior nasal secretions and sent in for Bordetella pertussis PCR. It is sensitive even after the first day of upper respiratory symptoms and stays positive for up to 14 days after the cough becomes severe. This represents most of the contagious phase of pertussis. The turnaround time on this test for this facility is more than 24 hours, but in many places it is more than 72 hours. She was empirically put on trimethoprim/sulfamethoxazole. She was offered the preferred agent, azithromycin, but she complained of gastric upset with "any of the mycins," which was presumed to include clarithromycin and erythromycin, the only other agents indicated for pertussis. (Levofloxacin does show some in vitro activity, but there is no clinical evidence of its efficacy against the illness.)

This is the classic story of pertussis, an infectious disease that had been very much in eclipse until the last decade. Many community practitioners are slow to consider it, believing it to be nearly extinct despite the nearly 28,000 cases reported per year. It is a serious respiratory illness that is extremely contagious by both respiratory droplets and hand-to-mouth transmission from contaminated surfaces.

Pertussis evolves through three phases. The catarrhal stage is a 1- to 2-week period of mild cough, upper respiratory symptoms, and low-grade fever. It is rapidly followed by the paroxysmal stage, when thick respiratory secretions cause bursts of coughing. A paroxysm describes many coughs in a single expiration, often followed by a gasping stridorous inspiration from which the "whooping cough" gets its name. (There is a recording of this cough at www.doitforyourbaby.com/mediaplayer.html.)

This phase includes post-tussive vomiting and occasionally diarrhea. Fever is typical, along with high white blood cell counts, with absolute lymphocytosis reaching as high as 20,000. This stage can progress for 1-2 weeks and usually lasts for 2 or 3 weeks. Not infrequently, it can last for 9 weeks. During the latter part of this phase, the patient does not appear ill but has 15-24 paroxysms per day, especially at night. Older patients may fracture ribs. Young infants who are too weak to mount an effective gasp may experience significant episodes of hypoxemia. The dehydration, malnutrition, and exhaustion often require inpatient intervention. At this point, patients have been ill for a month or longer.

The final stage of pertussis demonstrates a decline in the severity of the cough, but patients have a lingering cough and enervation for weeks and often months, with an increased susceptibility to subsequent infections, bronchospasm, and exacerbations of their chronic conditions.

Most pertussis occurs among adolescents and adults, whose immune status has declined over time. However, family members younger than 6 months old will not have had a complete series of immunizations. They are far more likely to have serious sequelae and death. In fact, 63% of infants younger than 12 months with pertussis require hospitalization, and 90 of the roughly 100 deaths in the United States each year are in children younger than 4 months. Primary (Bordetella) and secondary pneumonia, seizures and persistent seizure disorder, asthma, subdural hematoma from cough, encephalopathy, hypoxemia, and possible subsequent intellectual impairment are all well-documented complications. Dehydration and malnutrition are also short term risks during the acute illness.

Because the early symptoms are hard to recognize until the patient has been contagious for a week or more, and because there is no rapid-turnaround test for whooping cough, the best public heath strategy is widespread vaccination. Health care-centered outbreaks are well documented. Health care workers, especially those exposed to children younger than 12 months or immune-compromised patients (i.e., all emergency physicians), are especially encouraged to renew their immunization.

Parents' concerns about the dire side effects of vaccination are, for the most part, unfounded. They should discuss the rare episodes of high fever or other significant side effects associated with the vaccine with their pediatrician. However, reluctant moms and dads can no longer depend on "herd immunity." The American Academy of Pediatrics and the Centers for Disease Control and Prevention recommend that, except for prior allergic reactions or other rare exceptions, all children be vaccinated with acellular pertussis as part of the "Tdap" combination with tetanus and diphtheria. Shots should be scheduled for 2, 4, 6, and 15-18 months. Low-grade fever for 1-2 days and local tenderness and irritation are expected at the injection site after the fourth or fifth inoculation.

Eleven- and 12-year-old children should get a booster of Tdap, the adult formulation that contains a lower dose of acellular pertussis vaccine. If they have not gotten their booster, wound-related vaccination in the emergency department should be with Tdap (rather than Td). Adults who have not received a Td in the last 10 years should receive one dose of Tdap and boosters of Td every 10 years thereafter. Pregnant women who are more than 10 years out from their last Td are approved to receive wound-related Td in the second or third trimester but otherwise should get Tdap in the immediate postpartum period to avoid contracting the disease and exposing their infants. Likewise, all health care workers with exposures should receive one dose of Tdap, even if their most recent Td was as late as 2 years ago.

Emergency physicians are 10 times as likely to get pertussis from an infected patient than they are to contract hepatitis C from a contaminated hollow-needle stick. A single booster can prevent 2-4 months of illness and lost work, and reduce the possibility of passing a potentially serious respiratory illness to patents.

Whooping cough is back, and it's as bad as ever. We all should be fully engaged in diagnosing and treating this under-reported illness and in vaccinating our patients and ourselves against it.

Dr. Cordover is chair of ACEP's Well-Being Committee and Councillor for ACEP's Wellness Section.


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