PANCE Blueprint Pulmonary (12%)

Pertussis (Whooping Cough)

Patient will present as → a 24-year-old with 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 completed all immunizations required to attend school and has no known drug allergies

Patient will present with →  severe paroxysmal cough followed by an inspiratory high-pitched whoop, if untreated will develop a chronic cough lasting for weeks (watch video).

Caused by highly contagious gram negative bacteria: Bordetella Pertussis

  • Consider pertussis in adults with cough > 2 weeks

Diagnosis confirmed by nasopharyngeal secretions

Culture: criterion standard for diagnosis is isolation of the organism

Treat with Clarithromycin or Azithromycin

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."

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
IM_MED_Bordertella_v2.3_ Bordetella pertussis is a gram negative coccobacillus that is the causative agent of whooping cough. This organism is typically cultured on specialized medium called Bordet Gengou agar. Bordetella pertussis produces the pertussis toxin, which is an ADP ribosylating AB toxin that is involved in the colonization of the respiratory tract and the establishment of infection. This toxin catalyzes the ADP ribosylation of the Gi subunit, which prevents the G proteins from interacting with G protein coupled receptors on the cell membrane. The Gi subunits remain locked in an inactive or off state and are therefore unable to inhibit adenylyl cyclase activity leading to increased concentrations of cAMP. The increase in intracellular cAMP has several systemic effects including lymphocytosis and an increase in insulin leading to hypoglycemia.

The first 1-2 weeks of infection is typically called the catarrhal phase. The patient is usually most contagious during this stage of infection and signs and symptoms include nasal congestion, rhinorrhea, sneezing, and a low-grade fever. The catarrhal phase is followed by a paroxysmal phase which occurs during weeks 2-5 of infection. The paroxysmal phase is characterized by paroxysms of intense coughing lasting up to several minutes, occasionally followed by a loud inspiratory whooping sound, characteristic of this infection.

Antibiotic use can hasten the eradication of the bacteria and help prevent spread. Erythromycin is one of the preferred agents for patients aged 1 month or older.

View Bordetella Pertussis Picmonic

Question 1
Which of the following has been found to be an important reservoir in the transmission of pertussis?
A
Mosquitoes
Hint:
While mosquitoes have been implemented in the spread of several infectious diseases, pertussis is not one of them.
B
Adult humans
C
Dogs and cats
Hint:
Contact with dogs and cats has lead to the development of upper and lower respiratory infections that are caused by Bordetella bronchiseptica, but not pertussis.
D
White-tailed deer
Hint:
White-tailed deer are part of the transmission cycle for Lyme disease, not pertussis.
Question 1 Explanation: 
Since neither the vaccine nor the disease itself provides lasting immunity against pertussis, adult humans are an important reservoir in the transmission of pertussis.
Question 2
Which of the following is the most likely to develop into a persistent cough in the adult patient?
A
Pertussis
B
Allergic rhinitis
Hint:
See A for explanation.
C
Pharyngitis
Hint:
See A for explanation.
D
Heart failure
Hint:
See A for explanation.
Question 2 Explanation: 
Pertussis is suspected in patients with persistent cough that lasts longer than 2-3 weeks. Allergic rhinitis, pharyngitis and heart failure are all potential causes of acute cough.
Question 3
A 4 year-old boy is sent home from day care for a severe cough following one week of cold symptoms, including sneezing, conjunctivitis, and nocturnal cough. He presents with paroxysms of cough followed by a deep inspiration, and occasional post-tussive emesis. During severe paroxysms, he exhibits transient cyanosis. What is the most appropriate treatment for exposed contacts at his day care center?
A
Macrolide prophylaxis
B
Isolation
Hint:
Isolation of contacts is impractical and unnecessary.
C
Observation and treatment only if symptomatic
Hint:
Pertussis is rarely diagnosed before the paroxysmal stage, by which time exposure of contacts to the pathogen is assured.
D
Supportive care only
Hint:
While supportive care is essential in those contacts with symptoms, macrolide prophylaxis is mandatory in all contacts to prevent further spread of the illness.
Question 3 Explanation: 
All close contacts of a patient with pertussis should be treated with macrolide prophylaxis, regardless of age, immunization history, or symptoms.
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Influenza (ReelDx) (Prev Lesson)
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