Case 3

MACHINE GUN
KELLY
QUESTIONS TO BE ANSWERED
1. At this point, what diseases must be
entertained?
2. What is a typical picture of a Classic
illness of Pertussis?
3. What is/are the differential diagnosis?
4. How is the diagnosis of Pertussis achieved?
5. What are the complications of Pertussis?
6. What is the treatment and preventive
measures for Pertussis?
MACHINE GUN KELLY

Kelly, 7 mos old whose immunizations

were frequently postponed was brought
in because of paroxysmal cough of 9
days duration preceded 2 wks earlier by
low-grade fever, coryza and dry
irritating hacking cough becoming
progressively severe and paroxysmal &
ending with a high-pitched whoop
followed by vomiting.
MACHINE GUN KELLY

 Cough was likened to a machine gun

burst of uninterrupted coughing with the
chin and chest held forward; the tongue
protruding maximally, the eyes bulging
and watery and the face turning purple.
At the ER, he was visibly exhausted
with subconjunctival hemorrhages.
 CBC was done.
 Q1:
At this point, what
diseases must be
entertained?
MACHINE GUN KELLY
 Paroxysmal cough is limited to a few
conditions. The classic paroxysms, is
described as a repetitive series of 5 to 10
forceful coughs during a single expiration
followed by a sudden massive inspiratory
effort and a characteristic whoop occur as
air is forcefully inhaled through a narrow
glottis
 Attacks may be triggered by yawning,
sneezing or physical exertion
Textbook of Pediatric Infectious Diseases (Feigin)
MACHINE GUN KELLY
 The conditions that should be highly
entertained are: Pertussis syndromes
(Bordetella pertussis,B. parapertussis
etc),Acute bronchiolitis and Endobronchial
TB.
 Other infectious agents that may be confused
with pertussis are M. pneumoniae, C.
trachomatis, C. pneumoniae, Adenoviruses
and other respiratory viruses
 Q2:
What is a typical
picture of a Classic
illness of Pertussis?
Pertussis
 Classic illness occurs as a primary infection in
unimmunized children between 1 and 10
years of age
 The illness lasts 6 – 8 weeks and has 3
stages: catarrhal (most contagious),
paroxysmal (most diagnostic) and
convalescent
 The whoop consists of a high pitched
inspiratory noise following prolonged
expiration associated with coughing bursts
Pertussis
 In a severe attack,
the face becomes
flushed, florid and
cyanosed. The
tongue is often
protruded, the eyes
watery and sticky
mucus is brought
out from the mouth
Pertussis
 As a rule, the paroxysms are followed by
vomiting of ingested food or thick mucus
 In the very young (<6 mos.)where pertussis is
more severe, cough and catarrhal symptoms
are less marked (atypical) and the
presentation is frequently of recurrent attacks
of apnea and cyanosis. Whoop may be
absent
 Q3:
What is/are the
Differential Diagnosis?
Acute Bronchiolitis
 Most common serious
respiratory infection of
infancy
 RSV is the pathogen in
75-80% of cases
 90% aged 1 – 9 mos.
 CXR: hyperinflation of
lungs due to small
airway obstruction and Lung hyperinflation with flattening and
air trapping depression of diaphragm & increased
Bronchial markings

Illustrated Textbook of Pediatrics; Lissauer T , Clayden G.

 Acute Bronchiolitis
 Findings on examination:
– Sharp, dry cough
– Tachypnea
– Subcostal and intercostal retraction
– Hyperinflation of the chest
• Prominent sternum
• Liver displaced downwards
– Fine end inspiratory crackles
– High pitched wheezes
• Expiratory > inspiratory
– Tachycardia
– Cyanosis or pallor
Endobronchial Tuberculosis

 Signs and symptoms include

moderately high fever, anorexia, night
sweats, loss of weight and paroxysmal
cough ending in cyanosis
 Diagnosis established by (+) Mantoux
test and radiologic findings of
hyperaeration, atelectasis and enlarged
lymph nodes on lateral view
 Endobronchial Tuberculosis
 Roentgenographic
shadows: called Collapse-
Consolidation”/“Right
Middle Lobe Syndrome”
 Due to enlarged
peribronchial lymph nodes
impinging & compressing
neighboring regional
bronchus
 Segmental lesion resulting
in a fan shaped density on
x-ray representing Right Middle Lobe
atelectasis Syndrome

Tuberculosis in Infancy & Childhood; PPS Task Force on TB

Pertussis respiratory
complications
 Pneumothorax
 Mediastinal and
subcutaneous
emphysema
 Diaphragmatic
rupture
DISCLOSURE:
CBC revealed WBC of 40,000
with 90% lymphocytes
 Q4:
How is a diagnosis of
Pertussis achieved?
 Diagnosis of Pertussis
 Basis:
history and the clinical
presentation - apnea in infants,
prolonged cough, inspiratory whoop,
post-tussive vomiting or cyanosis and
lymphocytosis
– The history of absent or incomplete immunization &
contact with a known case help make the dx
– Usually, not suspected until the cough becomes
paroxysmal
– Laboratory: an absolute and relative lymphocytosis
to levels of 20,000 – 50,000 (resemble leukemia)
Diagnosis of Pertussis

 Isolation of B. pertussis is difficult

(fastidious organism) but possible with
nasopharyngeal swab culture on
Bordet-Gengou agar or Regan-Lowe
transport media inoculated at bedside
during catarrhal stage
 Q5:
What are the
complications of
Pertussis?
Complications
 Bronchopneumonia
(from B. pertussis or 20
bacterial infection) –
22% (Red Book)
 Seizures ( 2%)
 Encephalopathy (0.5%)
 Otitis media
 Subconjunctival
hemorrhages, epistaxis,
hemoptysis from
increased venous Subconjunctival hemorrhage
pressure following
coughing
 May precipitate
marasmus and
kwashiorkor
 Q6:
What is the treatment
and preventive
measures for
Pertussis?
 Treatment of Pertussis
 Infants <6 months and patients with severe
disease require hospitalization for supportive
care to manage apnea, hypoxia, feeding
difficulties etc.
 Antimicrobials given during catarrhal stage
ameliorate the disease. After cough is
established, antimicrobial agents have no
discernible effect but recommended to limit
the spread of organisms
 DOC: Erythromycin estolate 40-50 mkd for 14
days, or the newer macrolides (azithromycin,
Clarithromycin)
Red Book, 2003
Preventive measures
 Pertussis immune globulin is of no
benefit.
 All vaccines contain pertussis toxoid
 Universal immunization with a total of 5
doses of pertussis vaccine (contained in
DPT combination vaccines) is
recommended before school entry
 In the USA, DTaP is preferred for all
doses
 Erythromycin prophylaxis of close
contacts is recommended
DTP Adverse Reactions
 Local and febrile reactions (frequency
1 – 4%): redness, edema, induration and
tenderness at injection site. Drowsiness,
fretfulness, anorexia, vomiting, crying and
slight to moderate fever
 Allergic reactions 2/100,000 injections
 Seizures: within 48 hrs of DTPw
 Hypotonic-hyporesponsive episodes
 Hyperpyrexia

Red Book 2003

Contraindications & Precautions to
Pertussis immunization

 Contraindications:
– Immediate anaphylactic reaction
– Encephalopathy within 7 days
 Precautions
– Seizure with or without fever within 3 days
– Persistent, severe, inconsolable screaming or
crying for 3 or more hours within 48 hrs of
immunization
– Collapse or shock-like state (HHE) within 48 hrs.
– Temp >40.50C unexplained by another cause,
within 48 hrs of immunization
 Key Learning Points
 Pertussis is highly contagious for the
unimmunized or partly immunized child
 Pertussis immunity from natural infection is not
absolute and immunization may not prevent
infection because immunity acquired wanes with
time
– Immunization protects against symptomatic
disease rather than infection
(Vaccines: Children and Practice vol 6 No 1)
 Increasing evidence that pertussis in
adolescents and adults occurs more frequently
than previously thought (Vaccines; Children and Practice)
 Case 3
MACHINE GUN
KELLY