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Pertussis

Whooping Cough

Pertussis is a highly communicable infectious disease caused by Bordetella pertussis.


Presentation

The incubation period varies from 7 to 14 days. It is a disease of childhood with 90% of cases occurring below 5 years of age. 

The disease manifests in 3 stages: first is the catarrhal stage, followed by the paroxysmal stage and lastly, the convalescent stage. During the catarrhal stage, patients are highly infectious and their cultures from respiratory secretions are positive in most of the cases.

Malaise, anorexia, coryza, mild cough, mucoid rhinorrhoea and conjunctivitis are present. Paroxysms of cough begin about a week later. Paraoxysms with the classic inspiratory whoop are seen mainly in younger children in whom the lumen of the respiratory tract is compromised by mucosal secretion and mucosal oedema. The whoop results from air being forcefully drawn through the narrowed tract.

The disease runs an atypical course in partially immunised older children and in adults in whom cough is persistent and prolonged often without a whoop which makes diagnosis difficult for them.

Paraoxysms usually end in vomiting. Paraoxysmal stage lasts for about 2-6 weeks. Diminishing intensity and frequency of cough indicate the onset of the convalescent stage which may continue for 1-2 weeks.

Infants and young children are more sensitive to complications. Respiratory complications include otitis media, pneumonia either due to Bordetella pertussis or bacterial pneumonia.

At the peak of the disease, seizures and encephalopathy may occur. Malnutrition is often the end result in infancy and early childhood.

Fever
  • Tick-borne Rickettsia rickettsii Rocky Mountain spotted fever Rickettsia conorii Boutonneuse fever Rickettsia japonica Japanese spotted fever Rickettsia sibirica North Asian tick typhus Rickettsia australis Queensland tick typhus Rickettsia honei Flinders[en.wikipedia.org]
  • Both paroxysmal cough and absence of fever had high sensitivity (93.2% [95% CI, 83.2-97.4] and 81.8% [95% CI, 72.2-88.7], respectively) and low specificity (20.6% [95% CI, 14.7-28.1] and 18.8% [95% CI, 8.1-37.9]).[ncbi.nlm.nih.gov]
  • Abstract A 20 mo old male child, born at 31 weeks, presented to an out-of-hours General Practitioner (GP) with a 7 d history of cough and fever. There was history of post-tussive vomiting.[ncbi.nlm.nih.gov]
  • The disease usually starts with cold-like symptoms and maybe a mild cough or fever. After 1 to 2 weeks, severe coughing can begin. Unlike the common cold, pertussis can become a series of coughing fits that continues for weeks.[web.archive.org]
  • Early Symptoms The disease usually starts with cold-like symptoms and maybe a mild cough or fever. In babies, the cough can be minimal or not even there. Babies may have a symptom known as “apnea.” Apnea is a pause in the child’s breathing pattern.[cdc.gov]
Fatigue
  • Early symptoms are those of a cold: runny nose, low/no fever, mild cough After 1-2 weeks: vomiting, breathing problems, extreme fatigue, whooping sound For babies: gasping or gaging, breathing may stop, seizures Good to know… Pertussis is cyclical, with[acphd.org]
  • A severe infection may require hospitalization, and recovery can take months; the illness can have a lasting effect on lung function, leaving people with shortness of breath or fatigue.[well.blogs.nytimes.com]
  • […] in the body. 1 The major symptom of B. pertussis whooping cough disease is uncontrollable coughing. 2 Symptoms of B. pertussis at its onset are similar to the common cold, or an allergy attack with stuffy or runny nose, dry cough, loss of appetite, fatigue[nvic.org]
  • These include paroxysms of coughs proceeded by a whoop, fatigue after these coughing fits and potential vomiting during or after paroxysms.[healio.com]
  • ., infantile spasm, seizure, encephalopathy) until condition has stabilized Seizure three days after receiving DTP or DTaP vaccine Adverse drug reactions Mild reactions include fever, drowsiness, fretfulness, anorexia, headache, fatigue, and pain at injection[aafp.org]
Pathologist
  • Copyright 2018 Royal College of Pathologists of Australasia. All rights reserved.[ncbi.nlm.nih.gov]
  • Copyright 2017 Royal College of Pathologists of Australasia. Published by Elsevier B.V. All rights reserved. KEYWORDS: IgA; Pertussis toxin; serology [Indexed for MEDLINE] Free full text[ncbi.nlm.nih.gov]
Laboratory Technician
  • Although DFA testing has high specificity and provides results quickly, its sensitivity is lower than PCR assay, and specially trained laboratory technicians are required to perform the test.[web.archive.org]
Dentist
  • ., medical, nursing, and pharmaceutical), dentists, social workers, chaplains, volunteers, and dietary and clerical workers.[web.archive.org]
Pertussis
  • Pertussis may begin with cold-like symptoms or a dry cough that progress to episodes of severe coughing. Who gets pertussis? Pertussis can occur at any age.[web.archive.org]
  • Keywords: Bordetella pertussis ; pertussis; immunization; immunity 2005 Lippincott Williams & Wilkins, Inc.[web.archive.org]
  • Keywords: Bordetella pertussis ; pertussis ; immunization ; immunity 2005 Lippincott Williams & Wilkins, Inc.[journals.lww.com]
  • Pertussis: A Disease Affecting All Ages Bordetella pertussis is a highly contagious bacterium known to cause pertussis (whooping cough) and is transmitted via airborne droplets.[web.archive.org]
Cough
  • Go to sounds Go to Videos Whooping cough in teens Whooping cough in babies Whooping cough (pertussis) in a recognizable form evolves over a period of 2 weeks.[whoopingcough.net]
  • Whooping cough starts with a runny nose, tiredness and sometimes a mild fever, sore throat and a mild cough.[web.archive.org]
  • Coughing fits can come back if the person gets another respiratory illness. What are the complications of whooping cough? Complications of whooping cough are more common in infants and young children.[health.ny.gov]
  • Hence, the diagnostic feature is not so much the whoop as the persistent cough, cough, cough that empties the lungs before another breath can be drawn. The ferocity of the coughing may well cause vomiting.[patient.info]
Common Cold
  • Unlike the common cold, pertussis can become a series of coughing fits that continues for weeks. In infants, the cough can be minimal or not even there. Infants may have a symptom known as "apnea." Apnea is a pause in the child's breathing pattern.[web.archive.org]
  • During this time, symptoms are similar to the common cold. You’re highly contagious during this time. Stage 2: Severe, violent coughing spells develop during this stage.[healthline.com]
  • Persons with pertussis are infectious from the beginning of the catarrhal stage (runny nose, sneezing, low-grade fever, symptoms of the common cold) through the third week after the onset of paroxysms (multiple, rapid coughs) or until 5 days after the[web.archive.org]
  • Pertussis starts like a common cold with symptoms such as: Sneezing Runny nose Mild fever A mild cough During the next week or two, the cough gets worse, leading to severe coughing spells that often end with a whooping sound before the next breath, especially[saskatchewan.ca]
  • In the early stages it appears to be nothing more than the common cold, it is often not suspected or diagnosed until the more severe symptoms appear. Infected people are most contagious up to about 2 weeks after the cough begins.[solutionsdesignedforhealthcare.com]
Acute Cough
  • cough for 14 days plus one of the following: paroxysmal cough, post-tussive emesis, inspiratory “whooping,” and no other apparent cause or In an outbreak setting: acute cough for 14 days Confirmed Patient's illness meets criteria for “clinical case”[aafp.org]
  • cough for 14 days plus one of the following: paroxysmal cough, post-tussive emesis, inspiratory "whooping," and no other apparent cause or In an outbreak setting: acute cough for 14 days Confirmed Patient's illness meets criteria for "clinical case"[web.archive.org]
  • CDPH also used a suspect case category defined as an acute cough illness of any duration with detection of Bordetella pertussis –specific nucleic acid by polymerase chain reaction or an acute cough illness of any duration with 1 of the following: paroxysms[doi.org]
  • Confirmed case definition: 1) Acute cough illness of any duration, with isolation of Bordetella pertussis from a clinical specimen, or 2) cough illness lasting more than 2 weeks, with at least one of the following symptoms: paroxysms of coughing, inspiratory[ibis.health.state.nm.us]
Nausea
  • However, many contacts (35%) could not finish a 14-day course despite DOP, mostly because of nausea (85%) or diarrhea (72%).[ncbi.nlm.nih.gov]
  • The most common adverse effects associated with clarithromycin include epigastric distress, abdominal cramps, nausea, vomiting, and diarrhea.[cdc.gov]
  • 50 mg per kg divided into four doses per day for 14 days (maximum dosage: 2 g per day) 14-day regimen is considered standard; however, a seven-day regimen may have a similar Bordetella pertussis eradication rate; gastrointestinal side effects (e.g., nausea[aafp.org]
  • Possible side effects of whooping cough vaccine may include fever, redness and soreness or swelling where the injection was given, nausea, headache, tiredness and aching muscles.[conditions.health.qld.gov.au]
Cyanosis
  • We report a 28-day-old female infant with pertussis presenting as severe acute bronchiolitis with cyanosis. On admission, the patient's symptoms were similar to those of acute bronchiolitis.[ncbi.nlm.nih.gov]
  • However, occasional apneic episodes with cyanosis and peripheral lymphocytosis prompted us to examine the presence of Bordetella pertussis, which remains a significant cause of morbidity and mortality in unimmunized infants.[ncbi.nlm.nih.gov]
  • Typical manifestations include several weeks of cough which gradually develop into severe coughing fits, ending in a characteristic “whoop”, often with cyanosis and vomiting.[web.archive.org]
  • Antibodies were analyzed by commercial ELISA kits. 896 infants were followed to detect acute respiratory infections and paroxysms of coughing, inspiratory whoop, apnea, cyanosis or post-tussive vomiting.[ncbi.nlm.nih.gov]
Thrombosis
  • Autopsy showed medial thickening of small pulmonary arteries in 80% of patients who had pulmonary hypertension; intravascular aggregates of leukocytes or pulmonary thrombosis were not observed.[ncbi.nlm.nih.gov]
Lacrimation
  • Initial symptoms may be similar to a cold, with rhinorrhoea and lacrimation, or a dry cough followed by episodes of severe coughing. Fever may be absent or low-grade.[bestpractice.bmj.com]
  • The initial catarrhal stage presents with nonspecific symptoms of malaise, rhinorrhea, sneezing, lacrimation, and mild cough.[aafp.org]
  • Infants under 6 months of age rarely "whoop," but may present with apnea, gasping, or gagging -Coughing bouts can occur many times per hour, and may be accompanied by cyanosis, lacrimation, salivation, and post-tussive emesis -Sleep is often interrupted[pedclerk.bsd.uchicago.edu]
  • Uncomplicated disease lasts about 6 to 10 wk and consists of 3 stages: Catarrhal Paroxysmal Convalescent The catarrhal stage begins insidiously, generally with sneezing, lacrimation, or other signs of coryza; anorexia; listlessness; and a troublesome,[merckmanuals.com]
  • View/Print Table TABLE 1 Stages of Pertussis Infection Stage Duration(weeks) Symptoms Comment Catarrhal One to two Lacrimation, low-grade fever, malaise, mild conjunctival inflammation, rhinorrhea, late-phase nonproductive cough Insidious onset Gradually[aafp.org]
Blurred Vision
  • A previously healthy 27-year-old Hispanic man presented to an emergency department with headache, periorbital pressure, pain with ocular movements, and intermittent blurred vision that developed 1 day after administration of the diphtheria, tetanus, pertussis[ncbi.nlm.nih.gov]
Subcutaneous Emphysema of the Neck
  • A case of serologically confirmed pertussis occurred in an 18-year-old man presenting with pneumomediastinum, subcutaneous emphysema in the neck and chest, and persistent attacks of coughing with apnea that required treatment in the intensive care unit[ncbi.nlm.nih.gov]
Grunting
  • We report a case of severe pertussis in an infant who initially presented with persistent cyanotic cough, tachypnea, and grunting.[ncbi.nlm.nih.gov]
Generalized Seizure
  • Eighteen days after the onset of pertussis, generalized seizures began. Magnetic resonance imaging (MRI) indicated that marked demyelination without cytotoxic edema may have occurred to the patient.[ncbi.nlm.nih.gov]
Hematuria
  • Diagnostic work-up of unexplained hematuria and proteinuria during the illness revealed low serum complement component 3 (C3) levels. During follow-up, C3 levels remained low (400-600 mg/L).[ncbi.nlm.nih.gov]

Workup

The diagnosis is suggested after a clinical examination, a characteristic whoop and a history of contact with infected individual will be noted. On examination, a typical whoop will be heard. Patient may be febrile. Signs of coryza will be observed. Conjunctival suffusion and petechia and ulceration of the frenulum of the tongue are usual.

Blood reports will show lymphocytosis due to elaboration of lymphocyte promoting factor which is a characteristic of B. petussis. Lymphocytes may account for 90% of total WBC. Low erythrocyte sedimentation rate (ESR) may be noted.

Specific diagnosis depends upon recovery of pertussis from nasopharyngeal swab or cough plate cultures. Cultures are usually positive in early stage of the disease. Direct fluorescent antibody and counter immune electrophoresis are methods of rapid diagnosis, though these are rarely used in clinical practice.

Hyponatremia
  • Edema and mild hyponatremia were notable predominant symptoms of Bordetella pertussis infection. By exclusion of all other causes, the edema was probably due to inflammation and damage to the capillary wall caused by pertussis toxins.[ncbi.nlm.nih.gov]
Hyperviscosity
  • In this age group, high mortality and morbidity have been linked to the effects of the pertussis toxin, including lymphocytosis, pulmonary hyperviscosity and pulmonary hypertension.[ncbi.nlm.nih.gov]

Treatment

Immediate treatment should be started to prevent any respiratory or neurological complications which are serious in infants. Any complication or dehydration is an immediate indication for hospitalisation. Good nutrition and adequate hydration are important.

Antibiotics, mainly erythromycin, should be started early immediately in catarrhal stage as it will abort or reduce the intensity of the infection. It also terminates respiratory tract carriage of pertussis thus reducing the communicability. In the paroxysmal stage, antibiotics have little role to play in altering the course of the disease. Complications should be managed symptomatically [8].

Prognosis

The main objective of treatment is to reduce the spread of infection, ameliorate symptoms and prevent further compications. Thus, with proper diagnosis and prompt treatment the outlook of pertussis is very good with complete recovery. The chronic cough will resolve within 3 months.

Recurrence of cough and symptoms may occur after 6 months. In adolescents, adults and a little older children prognosis [6] is very good. Infants less than a year have a higher risk of complications, mainly bacterial pneumonia. Mortality of pertussis is mainly due to infants who have not received vaccination [7].

Etiology

The causative agent of this infection is Bordetella pertussis which is a Gram-negative coccobacillus. These bacteria are spread by droplet infection, as a result of an infected person’s sneeze or cough, these droplets are released in the air. This is a highly infectious disease which spreads to infants or children through the family members who may not even be aware of the infection. On inhalation of this infection, the bacteria attach to the nasopharyngeal epithelium, proliferate and spread through the ciliated epithelium.

There are a number of risk factors which facilitate its transmission, mainly individuals who are not immunised, infants and children who are in close contact with infected people and parents who refuse to give vaccination to their children due to misconceptions [2].

Health care providers who are in close contact with infected individuals are also at a risk. In case of an epidemic outbreak, all individuals staying in crowded areas, schools or hospitals are at high risk of contracting this infection.

Epidemiology

Pertussis occurs worldwide and continues to be a global problem in spite of vaccination being widely available. The post vaccination era has seen a 20 fold decline in the incidence. Periodic epidemics [3] however continue to occur worldwide.

Recent studies from WHO suggested that 260,000 children under the age of 5 years die from pertussis every year. Thus in spite of primary vaccination, pertussis continues to be a health hazard. Prior to vaccination, pertussis was a common cause of illness and death.

Pertussis occurs all throughout the year but is noticed more in summer. Pertussis affects all ages, males and females are equally affected. Children and infants are affected more, especially in the age range from 6 months to a year. A study in Australia reported that adults with obesity or asthma were more likely to have pertussis [4].

With improved vaccines, cases have been reported more in adults and adolescents. Infants maybe infected before vaccination. Alternatively, post vaccination immunity may wane in older children, who may suffer from a mild or modified form of the disease which is difficult to recognize.

Sex distribution
Age distribution

Pathophysiology

The organism is spread by droplets from infected, untreated patients. Pertussis main pathogenesis is due to the toxin that it elaborates. Clinical features depend upon the host response to various antigens, the capsule, cell wall and cytoplasm of the organism.

The bacterium gets adhered to the respiratory epithelium and destroys the ciliated epithelium which results in the first catarrhal stage. A lymphocytosis promoting factor probably plays an important role. Endotoxin does not seem to contribute to the pathogenesis. Bacteria also seem to invade the tissue and are seen in alveolar macrophages.

Pathological changes induce inflammation of the mucosal lining of the respiratory tract. Debris gets accumulated in the respiratory tract. Bronchopneumonia develops, with necrosis and desquamation of the superficial epithelium of the bronchi.
Bronchiolar obstruction and atelectasis can result from accumulation of secretions. Bronchiectasis may develop and persist. Due to accumulation of mucus secretions, coughing occurs.

Changes in brain and liver are seen in severe disease especially in infants and the cause is anoxia. The bacteria are not detected in blood culture [5].

Prevention

Strict respiratory isolation is desirable for 6-7 days after starting antibiotic therapy, thus reducing contact with other indiviuals. Chemoprophylaxis with erythromycin is ideal for immunised contacts under 2 years of age.

Routine primary immunisation at 6, 10, 14 weeks along with booster doses at 18 months and 5 years are a must [9].
Side effects of vaccination include fever, injection site pain, erythema and irritability.

All health care professionals should also take the vaccine.
Pertussis is an easily preventable disease as effective active immunisation is available [10].

Summary

Pertussis is an acute infectious disease caused by Bordetella pertussis. B. pertussis [1] is a Gram-negative coccobacillus. This is a serious infection common in infancy and childhood with serious complications. Pertussis occurs worldwide and epidemic outbreaks are common. Humans are both natural hosts and reservoirs of this infection.

Pertussis is highly communicable and spreads by droplet infection. It is also known as whooping cough or ‘cough of 100 days’. The symptoms at the start are mild and can be confused with other upper respiratory infections. It presents in 3 stages where it starts with an inflammatory coryza and later progresses onto severe episodes of coughing spasms.

Prevention is in the form of vaccination which is of great importance especially in children due to severity of secondary bacterial infections. The mainstay of treatment is antibiotics to reduce the severity of the disease.

It is known as whooping cough for the distinct ’whoop’ sound produced while coughing which is of a very high pitch and usually occurs when inhalation is attempted.

Patient Information

Pertussis or whooping cough is an acute infectious disease caused by a bacterium called as Bordetella pertussis. This is a highly contagious disease spread by close contact, sneezing, and coughing. This infection results in severe violent episodes of coughing with a characteristic whoop sound when the patient attempts to breathe.

The bacteria can cause a serious upper respiratory tract infection especially in infants which can result in severe complications and can even be fatal. When an infected person sneezes or coughs, small mucus droplets containing the Bordetella pertussis bacteria get released and the infection easily spreads to other people.

This infection persists for at least 6-8 weeks. It starts with symptoms similar to common cold and later on progresses to severe episodes of spasmodic coughing which are uncontrollable. Coughing can end in vomiting.

Immediate medical care should be provided as it helps to reduce the transmission of this infection as well as reduces severity and the complications which can occur. Antibiotics are started and infected individuals are kept separate especially away from infants and non-vaccinated individuals.

Blood tests are done but diagnosis is usually made after a good clinical examination. Infants need strict supervision as they have the highest risk of developing respiratory complications.

Prevention is the best approach for this disease. Vaccination is the most effective way of prevention against pertussis. All children should be vaccinated according to the immunisation schedule regularly. Booster doses should also be given. Adults above 65 years can take the adult vaccine especially in case of a pertussis epidemic.

With prompt antibiotics there is complete recovery. Pertussis has a good outlook provided immunisation is followed.

References

Article

  1. Walsh PF, Kimmel L, Feola M, Tran T, et al. Prevalence of Bordetella pertussis and Bordetella parapertussis in infants presenting to the emergency department with bronchiolitis. J Emerg Med. 2011 Mar;40(3):256-61.
  2. Bisgard KM, Pascual FB, Ehresmann KR, Miller CA, et al. Infant pertussis: who was the source? Pediatr Infect Dis J. 2004 Nov;23(11):985-9.
  3. Marconi GP, Ross LA, Nager AL. An upsurge in pertussis: epidemiology and trends. Pediatr Emerg Care. 2012 Mar;28(3):215-9.
  4. Liu BC, McIntyre P, Kaldor JM, Quinn H, Ridda I, Banks E. Pertussis in older adults: prospective study of risk factors and morbidity. Clin Infect Dis. 2012 Dec;55(11):1450-6.
  5. Mattoo S, Cherry JD. Molecular pathogenesis, epidemiology, and clinical manifestations of respiratory infections due to Bordetella pertussis and other Bordetella subspecies. Clin Microbiol Rev. 2005 Apr;18(2):326-82.
  6. Guinto-Ocampo H, Bennett JE, Attia MW. Predicting pertussis in infants. Pediatr Emerg Care. 2008 Jan;24(1):16-20.
  7. Vitek CR, Pascual FB, Baughman AL, Murphy TV. Increase in deaths from pertussis among young infants in the United States in the 1990s. Pediatr Infect Dis J. 2003 Jul;22(7):628-34.
  8. Allen A. Public health. The pertussis paradox. Science . 2013 Aug:341 (6145): 454–5.
  9. Baker JP, Katz SL . Childhood vaccine development: an overview. Pediatr Res. 2004 Feb :55 (2): 347–56.
  10. Edwards K, Decker MD. Pertussis vaccine. In: Plotkin SA, Orenstein WA. Vaccines. 4th ed. Philadelphia, PA: Saunders; 2004:471-528.

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Last updated: 2019-07-11 22:38