Pertussis (whooping cough)

Sabah Mohsin Al-Maamuri MD

Essentials of diagnosis & typical features: Pertussis is extremely contagious, with attack rates
as high as 100% in susceptible individuals exposed to
 Prodromal catarrhal stage (1–3 weeks)
aerosol droplets at close range.
characterized by mild cough, coryza, and
fever. Neither natural disease nor vaccination provides
 Persistent staccato, paroxysmal cough ending complete or lifelong immunity against pertussis re-
with a high-pitched inspiratory “whoop.” infection or disease. Protection against typical
 Leukocytosis with absolute lymphocytosis. disease begins to wane 3-5 yr after vaccination.
 Diagnosis confirmed by fluorescent stain or
Coughing adolescents and adults (usually not
culture of nasopharyngeal secretions.
recognized as having pertussis) are the major
General consideration: reservoir for B. pertussis and are the usual sources of
infection for infants and children. The incubation
Pertussis is an acute respiratory tract infection that
period is 7 to 10 days.
was well described initially in the 1500s. Sydenham
first used the term pertussis, meaning "intense cough", Symptoms and signs:
in 1670; it is preferable to whooping cough because
The onset of pertussis is insidious, with catarrhal
most infected individuals do not “whoop.”
upper respiratory tract symptoms (rhinitis, sneezing,
Pertussis is an acute, highly communicable infection and an irritating cough). Slight fever may be present;
of the respiratory tract caused by Bordetella pertussis temperature greater than 38.3°C suggests bacterial
(gram negative fastidious coccobacillus) and superinfection or another cause of respiratory tract
characterized by severe bronchitis. Transmission infection. After about 2 weeks, cough becomes
occurs by close contact with cases via aerosolized paroxysmal, characterized by 10–30 forceful coughs
droplets. Children usually acquire the disease from ending with a loud inspiration (the whoop). Infants
symptomatic family contacts. Adults who have mild and adults with otherwise typical severe pertussis
respiratory illness, not recognized as pertussis, often lack characteristic whooping. Vomiting
frequently are the source of infection. Asymptomatic commonly follows a paroxysm (post-tussive
carriage of B. pertussis is not recognized. Infectivity is vomiting). Coughing is accompanied by cyanosis,
greatest during the catarrhal and early paroxysmal sweating, prostration, and exhaustion. This stage
cough stage (for about 4 weeks after onset). lasts for 2–4 weeks, with gradual improvement.
Cough suggestive of chronic bronchitis lasts for
B. pertussis organisms attach to the ciliated
another 2–3 weeks. Paroxysmal coughing may
respiratory epithelium and multiply there; deeper
continue for some months and may worsen with
invasion does not occur. Disease is due to several
intercurrent viral respiratory infection. In adults, older
bacterial toxins, the most potent of which is "pertussis
children, and partially immunized individuals,
toxin", which is responsible for lymphocytosis and
symptoms may consist only of irritating cough lasting
many of the symptoms of pertussis.
1–2 weeks. In the younger unimmunized child,
Bordetella parapertussis causes a similar but milder symptoms of pertussis last about 8 weeks or longer.
syndrome. Clinical pertussis is milder in immunized children.

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 worsening or recurrence of paroxysmal
coughing.
Laboratory findings:
4. Otitis media: is common.
White blood cell counts of 20,000–30,000/µL with 70– 5. Residual chronic bronchiectasis is infrequent
80% lymphocytes typically appear near the end of the despite the severity of the illness.
catarrhal stage. 6. Apnea and sudden death may occur during
a particularly severe paroxysm.
Culture is considered the “gold standard” for
7. Seizures complicate 1.5% of cases and
laboratory diagnosis of pertussis.
encephalopathy occurs in 0.1%. The
Identification of B pertussis by culture or polymerase encephalopathy frequently is fatal. Anoxic
chain reaction (PCR) from nasopharyngeal swabs or brain damage, cerebral hemorrhage, or
nasal wash specimens proves the diagnosis. After 4– pertussis neurotoxins are hypothesized, but
5 weeks of symptoms, cultures and fluorescent anoxia is most likely the cause.
antibody tests are almost always negative. Charcoal 8. Epistaxis and subconjunctival
agar containing an antimicrobial should be inoculated hemorrhages are common.
as soon as possible; B pertussis does not tolerate 9. Increased intrathoracic and intraabdominal
drying or prolonged transport. PCR detection is pressure may lead to rib fractures,
replacing culture in some hospitals because of pneumothorax, incontinence, and hernias.
improved sensitivity, decreased time to diagnosis and
Differential diagnosis of sporadic "prolonged cough":
cost.
Enzyme-linked immunosorbent assays (ELISA) for 1. Bordetella parapertussis and Bordetella
detection of antibody to pertussis toxin or filamentous bronchiseptica.
hemagglutinin may be useful for diagnosis but are 2. Mycoplasma pneumonia
currently not widely available, and interpretation of 3. Chlamydia trachomatis and Chlamydophila
antibody titers may be difficult in previously pneumonia
immunized patients. 4. Respiratory tract viruses, particularly
The chest x-ray reveals thickened bronchi and adenoviruses and respiratory syncytial viruses.
sometimes shows a “shaggy” heart border, indicating
Prevention:
bronchopneumonia and patchy atelectasis.
Pre-exposure prophylaxis: Active immunization with
Complications:
DTP vaccine should be given in early infancy.
1. Bronchopneumonia: due to superinfection is Acellular pertussis (DTaP) vaccines cause less fever
the most common serious complication. It is and fewer local and febrile systemic reactions and
characterized by abrupt clinical deterioration have replaced the former whole cell vaccines.
during the paroxysmal stage, accompanied by
Post-exposure prophylaxis:
high fever and sometimes a striking leukemoid
Care of Exposed People: Household and Other
reaction with a shift to predominantly
Close Contacts who are unimmunized or
polymorphonuclear neutrophils.
underimmunized should have pertussis immunization
2. Atelectasis: is a second common pulmonary
initiated or continued using age-appropriate products
complication. Atelectasis may be patchy or
according to the recommended schedule as soon as
extensive and may shift rapidly to involve
possible ( tetanus toxoid, reduced-content diphtheria,
different areas of lung.
and acellular pertussis vaccine (Tdap) in children 7
3. Intercurrent viral respiratory infection: is
through 10 years and classic DTaP series for others).
also a common complication and may provoke
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Chemoprophylaxis should be given to exposed family, Trimethoprim-sulfamethoxazole is an alternative for
close and hospital contacts whatever their age or patients older than 2 months of age who cannot
vaccination status. The agents, doses, and duration tolerate macrolides or who are infected with a
of prophylaxis are the same as for treatment of macrolide-resistant strain.
pertussis
Penicillins and first- and second-generation
Hospitalized children with pertussis should be cephalosporins are not effective against B pertussis.
isolated because of the great risk of transmission to
Corticosteroids reduce the severity of disease but
patients and staff. In addition to standard precautions,
may mask signs of bacterial superinfection.
droplet precautions are recommended for 5 days after
initiation of effective therapy, or if appropriate Albuterol (0.3–0.5 mg/kg/d in four doses) has
antimicrobial therapy is not given, until 3 weeks after reduced the severity of illness, but tachycardia is
onset of cough. common when the drug is given orally, and aerosol
administration may precipitate paroxysms.
Child Care: Pertussis immunization and
chemoprophylaxis should be given as recommended B. General measures:
for household and other close contacts. Nutritional support during the paroxysmal phase is
important. Frequent small feedings, tube feeding, or
Students and staff members: with pertussis should
parenteral fluid supplementation may be needed.
be excluded from school until they have completed 5
days of the recommended course of antimicrobial Minimizing stimuli that trigger paroxysms is probably
therapy. People who do not receive appropriate the best way of controlling cough. In general, cough
antimicrobial therapy should be excluded from school suppressants are of little benefit.
for 21 days after onset of symptoms.
C. Treatment of complications:
Treatment: Respiratory insufficiency due to pneumonia or
other pulmonary complications should be treated with
A. Specific measures:
oxygen and assisted ventilation if necessary.
Antibiotics may "ameliorate" early infections but have
Convulsions are treated with oxygen and
no effect on clinical symptoms in the paroxysmal
anticonvulsants.
stage.
Bacterial pneumonia or otitis media requires
A macrolide group is the drug of choice because it
additional antibiotics.
promptly terminates respiratory tract carriage of B
pertussis. Patients should be given erythromycin Prognosis:
estolate (40 mg/kg/24 h in four divided doses for 14
The prognosis for patients with pertussis has
days). Clarithromycin for 7 days and azithromycin for
improved in recent years because of excellent
5 days were equal to erythromycin for 14 days in one
nursing care, treatment of complications, attention to
small study.
nutrition, and modern intensive care. However, the
Until additional information is available, azithromycin disease is still very serious in infants under age 1
is the drug of choice for treatment or prophylaxis of year (esp <3 mo); most deaths occur in this age
pertussis in infants, in whom the risk of developing group. Children with encephalopathy have a poor
severe pertussis and life-threatening complications prognosis. Case-fatality rates are approximately 1%
outweighs the potential risk of infantile hypertrophic in infants younger than 2 months of age.
pyloric stenosis (IHPS) with azithromycin.

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