ACEP ID:

Pediatric Emergency Medicine

Pertussis

Sean M. Fox, MD
Assistant Professor
Adult and Pediatric Emergency Medicine
Carolinas Medical Center, Charlotte, NC

I don’t get around to watching the news much anymore (and for the most part that is not a bad thing as the idea of an objective reporter of news has morphed into someone who reiterates talking points over and over again). But, fortunately for me, my wife is able to keep me up to speed. Naturally, she is objective. Today, she told me of the outbreak in Washington State of pertussis. So, let’s look at that.

 

Pertussis is a great example of the fact that immunizations do not rid the planet of diseases, but rather keep them at bay.

  • The number of reported cases of pertussis has been on the rise since 1980s.
  • The increased rate is particularly seen in teenagers and infants (<5 mo)
  • In Washington State, there have been >600 cases reported thus far in 2012. 2011 had only 100 by the same time. 

The Problem: Pertussis can be deadly, but it often presents just like nonspecific viral illnesses.

  • Initial catarrhal stage (lasting 7-10 days) is indistinguishable from minor viral respiratory illness with coryza, low-grade fevers, and mild cough.
  • The paroxysmal stage (can last up to 10 weeks)
    • The cough is initially minor and intermittent, but becomes paroxysmal.
    • The paroxysms are an attempt to expel the thick mucous.
    • Paroxysms typically end with an inspiratory whoop and post-tussive emesis can be seen.
    • Cyanosis can occur.  Apnea also can be seen.
    • The very young, who are at greatest risk, often do not present classically.
      • In infants, the cough can be minimal or even absent.
      • Apnea may be the only symptom (SO THINK ABOUT THIS WITH ALTE).
      • >50% of kids <12 months with pertussis will require hospitalization.
        • 50% will have apnea, 20% will have pneumonia, and 1% will die.
        • Encephalopathy occurs in 20% of mortality cases (due to hypoxia or possibly toxin)
    • The convalescent stage (another 1-3 weeks) demonstrates a slow resolving of the paroxysmal coughs.  Unfortunately, paroxysms often recur with subsequent respiratory infections for months afterwards.

High-Risk Patients

  • Infants < 12 months are at greatest risk for severe disease and death.
  • Pregnant women (as they will expose their newborns)
  • Healthcare providers (which is why we all have had to have our booster shots)
  • Anyone who may expose young children or pregnant women (so that is almost everyone)

Vaccination

  • Primary vaccination – DTaP at 2, 4, and 6 months and again between 15-18 months and 4-6 years.
  • Boosters for teens and adults with Tdap, so while stamping out tetanus, squash pertussis too.
  • It is recommended that pregnant women get Tdap during pregnancy (after 20 weeks gestation) to pass on extra protection to their infants.

Treatment

  • If you suspect pertussis, consult your local health agency.
  • Consider it with a patient who has a cough illness lasting 2 or more weeks PLUS one of the following:
    • Paroxysms of coughing
    • Inspiratory Whoop
    • Vomiting associated with coughing
  • Treat with Macrolide (traditionally Erythromycin has been recommended, but azithromycin can be used in all age groups – Erythromycin is associated with hypertrophic pyloric stenosis in infants <1month). Trimethoprim-sulfamethoxazole would be an alternative for kids >2mos.

Reference

1. State of Washington Department of Health News Alert. Available at http://www.cdc.gov/pertussis/clinical/features.html. Accessed July 27, 2012.

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