PANCE Blueprint Pulmonary (10%)

Patient will present with → a 6-month-old boy brought to the clinic by his mother, who is worried about his persistent and severe coughing episodes that have been ongoing for two weeks. She describes the cough as initially mild but has since progressed to intense bouts followed by a high-pitched "whooping" sound when he takes a breath. These episodes often lead to vomiting and have been particularly distressing at night. The mother also mentions that her son had a mild fever and runny nose before the cough started. On examination, the infant has clear lung sounds between coughing fits, but during an episode, inspiratory whoops can be heard. A nasopharyngeal swab is taken for further testing. (watch video)

Patient will present as → a 24-year-old with an increasing cough for 3 weeks. The cough comes and goes, sometimes lasting for 10 minutes and causing gasping inhalations. The cough was preceded by a mild cough and cold 2 weeks ago. She has no known drug allergies. The patient's immunizations are not up-to-date. (alternate presentation)

Caused by the highly contagious gram-negative bacteria Bordetella Pertussis

• Consider pertussis in adults with cough > 2 weeks
• Unvaccinated or individuals whose vaccinations are not up-to-date
• Symptoms are initially those of nonspecific upper respiratory infection (catarrhal stage ) followed by paroxysmal or spasmodic coughing that usually ends in a prolonged, high-pitched, crowing inspiration (the whoop)

Diagnosis is confirmed by nasopharyngeal secretions

• In the setting of a pertussis outbreak or known close contact with a confirmed case, the presence of a cough lasting ≥ 2 weeks is sufficient for clinical diagnosis (even in the absence of other symptoms)
• For patients with less than two weeks of cough in whom there is a clinical concern for pertussis, perform both culture and PCR for B. pertussis
• For patients with two to four weeks of cough, perform both culture and PCR
• For patients with more than four weeks of cough, only serology is useful

Treat with macrolide antibiotic erythromycin or azithromycin

• Trimethoprim/sulfamethoxazole may be substituted in patients ≥ 2 months who are intolerant of or hypersensitive to macrolide antibiotics
• Supportive care with steroids and/or beta2 agonists

"What do you do if your patient is a 4-year-old diagnosed with pertussis and attends a daycare? All close contacts of a patient with pertussis should be treated with macrolide prophylaxis regardless of age, immunization history, or symptoms."

Postexposure Antimicrobial Prophylaxis CDC Guidelines

Children should get 5 doses of DTaP vaccine: one dose at each of the following ages:

• 2 months
• 4 months
• 6 months
• 15–18 months
• 4–6 years

Adolescents 11 through 18 years of age (preferably at age 11-12 years) should receive a single booster dose of Tdap

• One dose of Tdap is also recommended for adults 19 years of age and older who did not get Tdap as an adolescent
• Expectant mothers should receive Tdap during each pregnancy, preferably at 27 through 36 weeks
• Tdap should also be given to 7-10-year-olds who are not fully immunized against pertussis
• Tdap can be given no matter when Td was last received