case of a coughing kid anna chollet, md/mph march 6, 2013
TRANSCRIPT
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Case of a Coughing Kid
Anna Chollet, MD/MPHMarch 6, 2013
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Intermittent forceful coughing attacks for 2+ weeks, "like the child is going to die"
Especially at night or in car seat
Coughs up "thick saliva"
Sometimes vomits only when coughing.
19 mo F presents w/cough
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More history
Low grade fevers
One episode of diarrhea
Decreased appetite
Lives with mom and another family including 4 other children; no known sick contacts
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Physical Exam
HR 145, Temp 98.5, Oxygen sat % 92
HEENT: "Congested nares"; otherwise wnl
CV: regular rhythm, no murmursPULM: Clear to ausc bilaterallyAB: soft, NT, ND, normal bowel soundsEXT: no cyanosisNEURO: interactive, playful, occas
cough
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Next steps?
What else do you want to know?
What is on your differential?
What tests would you order?
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Lab
Bordatella pertussis culture:
POSITIVE!
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B. pertussis or whooping coughTos Ferina o Tos
Convulsiva3 Stages:
1. Catarrhal: 7-10 days. Coryza, low fever, mild cough
2. Paroxysmal: 1-6 weeks, up to 10 weeks. Paroxysms of coughs, thick mucus expulsion, inspiratory "whoop", cyanosis, vomiting
3. Convalescent: 7-21 days. Gradual recovery, decreasing paroxysms, may recur
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Characteristics
Paroxysmal cough
Inspiratory "whoop"
Prolonged cough (2+ weeks)
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PathogenesisInfection by respiratory droplets
Bacteria target cilia of respiratory mucosa
Bacteria produce toxins which immobilize cilia, damage respiratory epithelium, induce mucus release, inflammation of resp tract
Incubation period: usually 7-10 days
Most contagious during catarrhal period (1-2 weeks) and first 2 weeks of paroxysmal phase
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Epidemiology
Worldwide annual incidence in children < 1 yo is 10 million
400,000 deaths per year worldwide
Incidence has increased since 1980s in US:
- more sensitive tests - increased awareness - improve reporting- whole cell > acellular vaccine
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Epidemiology
Most affected: Infants too young to be fully immunized, less than 6 months old
Hospitalized infants: Apnea 50%, PNA 20%, 1% SZ, 1% death
~50% reported cases in adolescents and adults
Usually contracted from family member, especially parents!
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Clinical Case Definition
If outbreak, cough >= 2 weeks
If endemic or sporadic case, cough >=2 wks
plus 1+ of the following:- paroxysms of cough- inspiratory "whoop"- post-tussive vomiting- no other apparent cause
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Diagnosis
Acute cough with positive culture
Positive PCR with clinical case definition
Clinical case definition and known exposure to patient with positive culture or PCR
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TestingGold std: nasopharyngeal swab
culture BUT low sensitivity (30-60%-->1-3%
by 3 weeks)
PCR: nasopharyngeal sample. More sensitive, rapid results BUT no inter-lab std, more false positives
WBC < 9,400 to rule out
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Testing continued
Some evidence that PCR + serology is most sensitive for ruling out in exposed pts (level 2)
CDC does not accept serology for diagnosis
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Complications
Pneumonia, pneumothorax, pulmonary hypertension, apnea, respiratory failure, syncope
Seizure, encephalopathy, cerebral hypoxia
FTT from vomiting, incontinence
Inguinal hernia, rectal prolapse, rib fx
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But she was vaccinated!
Vaccine does not eliminate risk for infection
Increased cases in 2012 nationwide
Waning immunity?
Drift in bacterial strains?
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When and why antibiotics?
Start if pt >1 yo within 3 wks of cough onset
if pt <1 yo within 6 wks of cough onset
Reduce transmission to others
Unlikely to improve dz course
Prophylaxis in exposed persons
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Post-exposure prophylaxisSame dosage as for treatment
Within 3 weeks of exposure of close contact:
- close proximity to symptomatic pt >1 hr
- direct contact with secretions of symp pt
- face to face exposure w/in 3 ft of symp pt
High risk pts:< 1 yo, 3rd trim,
immunocompromised, underlying lung disease
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Vaccines: safest prevention
DTaP: 2, 4, 6 mos, then 15-18 mos, then 4-6 yrs
Close contact < 7 yo --> complete series
Close contact <7 yo: if 3rd dose >6 mo prior to exposure --> give 4th dose
Tdap for 10-64 yo post-exposure not eval'd
Infection 6x more likely in unvaccinated
At least 2 doses needed for protection. 5-6 yrs of protection
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Treatment
Azithromycin< 6 mo 10 mg/kg/day x 5 days>= 6 mo 10 mg/kg/day on day 1 then 5 mg/kg/day for day 2-5Adult (or adult size?) 500 mg day 1, then 250 mg day 2-5
TMP-SMX in pts >2 months old and macrolide ineffective/not tolerated
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Treatment Setting
Home care if uncomplicated dz
No school/work for 5 days after starting abxIf no Rx, no school until 21 days of cough
No exclusions for asymptomatic contacts
Hospitalize if apnea, hypoxia, pneumonia, resp distress, need for supp O2, extreme leukocytosis, poor feeding
Droplet precautions until 5 days of abx
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Take Home
Stay vigilant for pertussis in cough > 2 wks!
Vaccinate!
Treat contacts, if possible
Azithro easier to use than erythro
Advise parents on expected time course
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Referenceshttp://www.cdc.gov/pertussis/clinical/features.html
Brown, M. Pertussis outbreaks on the decline, but immunization gaps still exist. AAFP News Now 1/31/2013 www.aafp.org/online/en/home/publications/news/news-now/health-of-the-public/20130131pertussisdown.html
Via DynaMed "Pertussis":Wood, N, McIntyre P. Pertussis: review of epidemiology, diagnosis, management and
prevention. Paediatric Respiratory Review. 2008 Sep;9(3): 201-11.
Cornia PB, Hersh AL, Lipsky BA, Newman TB, Gonzalez R. Does this coughing adolescent or adult parent have pertussis? JAMA. 2010 Aug 25;304(8): 890-6
Heininger U. Update on pertussis in children. Expert Rev Anti Infect Ther. 2010 Feb; 8(2): 163-173
MMWR Recomm Rep 2005 Dec 9;54 (RR-14):1 full-text
Wkly Epidemiol Rec 2010 Oct 1;85(40): 385
JAMA 2000 Dec 27;284(24): 3145