Transcript Case 3 MACHINE GUN KELLY

Case 3
MACHINE GUN
KELLY
QUESTIONS TO BE ANSWERED
1.
2.
3.
4.
5.
6.
At this point, what diseases must be
entertained?
What is a typical picture of a Classic
illness of Pertussis?
What is/are the differential diagnosis?
How is the diagnosis of Pertussis achieved?
What are the complications of Pertussis?
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
air trapping
Lung hyperinflation with flattening and
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
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Roentgenographic
shadows: called CollapseConsolidation”/“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
atelectasis
Right Middle Lobe
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
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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
pressure following
coughing
May precipitate
marasmus and
kwashiorkor
Subconjunctival hemorrhage
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