Pertussis

Last updated: February 13, 2023

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Pertussis, or whooping cough, is a highly infectious disease of the respiratory tract caused by the gram-negative bacteria Bordetella pertussis. The disease is mainly transmitted via airborne droplets and most commonly occurs in children. Typically, pertussis manifests in three stages, with the second and third stages characterized by intense paroxysmal coughing that is followed by a distinctive whooping sound on inhalation and, in some cases, vomiting. Young infants may not develop the typical cough, and often present with apnea and cyanosis instead. The disease is most often diagnosed via laboratory tests, especially detection of B. pertussis in bacterial culture. However, as test results may take time to obtain, treatment should be initiated as soon as clinical suspicion of pertussis arises. Subsequent management includes hospitalization of high-risk patients (e.g., infants) and antibiotic therapy with macrolides. These may lessen the length and severity of the disease if administered early, while also reducing infectivity and further disease transmission. Macrolides are also the drug of choice for post-exposure prophylaxis (PEP), which is recommended for all people with a recent history of exposure to pertussis. PEP is administered regardless of the individual immunization status, as both vaccination and prior infection may shorten the disease course, but do not provide full immunity.

  • Typically a childhood disease (particularly children aged < 1 year); however, older patients are increasingly affected. [1][2]
  • High rate of infections in newborns: Tdap vaccine is recommended for pregnant women between weeks 27 and 36 of gestation. [2][3]

Epidemiological data refers to the US, unless otherwise specified.

References:[2]

Catarrhal stage (1–2 weeks)

Paroxysmal stage (2–6 weeks)

  • Intense paroxysmal coughing (often occurring at night)
    • Followed by a deep and loud inhalation or high-pitched whooping sound
    • Accompanied by tongue protrusion , gagging, and struggling for breath
    • Possibly accompanied by cyanosis
    • Increases in frequency and severity throughout the stage
    • Followed by the expulsion of phlegm or posttussive vomiting (risk of dehydration)
  • Potential bleeding of the conjunctiva, petechiae, and venous congestion
  • Infants (< 6 months) may only develop apnea and not the characteristic cough.

Convalescent stage (weeks to months)

  • Progressive reduction of symptoms
  • Coughing attacks may persist over several weeks before resolving

The typical whooping cough manifests mainly in children aged 6 months to 5 years. The individual stages of the disease may be indistinguishable in young infants and adults.

Catarrhal stage manifests with Coryza, while the Paroxysmal stage manifests with Posttussive vomiting and whooPing cough.

References:[6][7]

A presumptive diagnosis of pertussis may be made based on clinical history and findings. However, if possible, laboratory tests should be performed to confirm the diagnosis.

History [7]

Laboratory tests [8][9]

As B. pertussis only grows on respiratory epithelium, blood cultures are always negative.

The differential diagnoses listed here are not exhaustive.

General approach [10]

  • Early initiation of treatment, especially in high-risk patients (e.g., infants), while confirmatory laboratory tests are pending
  • Hospitalization and monitoring: infants < 4 months; severe cases (e.g., respiratory distress, cyanosis, apnea, inability to feed)
  • Oxygen administration with humidification
  • Increased fluid intake and nutritional support
  • If necessary, sedation

Medical therapy [11][12]

References:[13][14]

We list the most important complications. The selection is not exhaustive.

  • In children > 3 months: very good; lengthy convalescence, but full recovery
  • In children < 3 months: mortality 1–3%, particularly due to apnea
  • Increased risk for complications
    • Premature infants
    • Children < 6 months
    • People with underlying cardiac, pulmonary, neurologic, or neuromuscular disease

References:[10]

Immunization [2][15][16]

Post-exposure prophylaxis [18][19][20]

  • Indications
    • All household contacts of a pertussis case, regardless of their vaccination status
    • People at high risk of developing severe pertussis, including:
      • Infants younger than 12 months
      • Pregnant individuals in their third trimester of pregnancy
      • Individuals with conditions that may be exacerbated by a pertussis infection (e.g., immunocompromization due to HIV, conditions affecting the lungs)
    • People who have close contact with others at high risk of developing severe pertussis (e.g., workers in neonatal intensive care units, childcare settings, or maternity wards)
  • Regimen: choice of antibiotics is identical to treatment recommendations (see “Therapy” above)
  • Isolation
    • Required for 5 days after initiation of antibiotic therapy
    • Without antibiotic treatment: minimum of 3 weeks after the onset of first symptoms

Pertussis is a notifiable disease. [21]

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  2. Pertussis. https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/pert.pdf. . Accessed: March 19, 2017.
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  8. Pertussis (Whooping Cough) - Specimen Collection. https://www.cdc.gov/pertussis/clinical/diagnostic-testing/specimen-collection.html. Updated: September 8, 2015. Accessed: March 19, 2017.
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  10. Yeh S. Pertussis Infection in Infants and Children: Treatment and Prevention. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/pertussis-infection-in-infants-and-children-treatment-and-prevention.Last updated: January 13, 2016. Accessed: March 19, 2017.
  11. Pertussis (Whooping Cough) - Treatment. https://www.cdc.gov/pertussis/clinical/treatment.html. Updated: September 8, 2015. Accessed: March 19, 2017.
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  15. Vaccines and Preventable Diseases - Pertussis: Summary of Vaccine Recommendations. https://www.cdc.gov/vaccines/vpd/pertussis/recs-summary.html. Updated: June 22, 2016. Accessed: March 19, 2017.
  16. Immunization Schedules - Catch-up Schedule. https://www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html. Updated: February 6, 2017. Accessed: March 19, 2017.
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  21. Pertussis (Whooping Cough) - Surveillance and Reporting. https://www.cdc.gov/pertussis/surv-reporting.html. Updated: January 10, 2017. Accessed: March 19, 2017.
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  23. UpToDate. Recommended oral antimicrobial treatment and postexposure prophylaxis for pertussis, by age group. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/image?imageKey=PEDS%2F75339&topicKey=ID%2F8044&rank=1~150&source=see_link&search=pertussis.Last updated: January 1, 2017. Accessed: March 19, 2017.
  24. Ideno S, Miyazawa N, Ishikawa S et al. Anesthetic management of a patient with severe subcutaneous and mediastinal emphysema due to pertussis infection. Masui. 2014; 63 (6): p.671-4.

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