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Transcript Good Morning!
Good Morning!
Friday, August 3rd 2012
Semantic Qualifiers
Symptoms
Acute /subacute
Chronic
Localized
Diffuse
Single
Multiple
Static
Progressive
Constant
Intermittent
Single Episode
Problem Characteristics
Ill-appearing/
Toxic
Well-appearing/
Non-toxic
Recurrent
Localized
problem
Systemic
problem
Abrupt
Gradual
Acquired
Congenital
Severe
Mild
New problem
Painful
Nonpainful
Recurrence of
old problem
Bilious
Nonbilious
Sharp/Stabbing
Dull/Vague
Illness Script
Predisposing Conditions
Age, gender, preceding events (trauma, viral illness, etc),
medication use, past medical history (diagnoses, surgeries,
etc)
Pathophysiological Insult
What is physically happening in the body, organisms involved,
etc.
Clinical Manifestations
Signs and symptoms
Labs and imaging
Predisposing Conditions: Pertussis
Highest incidence
Infants <6mos (not completely immunized)
Adolescents (due to waning immunity)
• Important infectious source for infants/children
Risk factors
Childcare, school outbreaks
Sick caregiver
Pathophysiology: Pertussis
Organism: Bordetella pertussis
Gram-negative pleomorphic bacillus
Bordetella parapertussis – milder disease
Transmitted via coughing (aerosolized droplets)
Infect ciliated epithelium of respiratory tract
Toxins cause local and systemic effects
Plugs of necrotic bronchial epithelial tissues and
thick mucus in airways
VERY contagious during earliest (catarrhal) stage
Clinical Manifestations: Pertussis
Classic pertussis syndrome (ages 1-10yrs)**
3 stages
Catarrhal – nonspecific signs; lasts 1-2 weeks
• Nasal congestion, rhinorrhea, sneezing, tearing, low-grade fever
Paroxysmal – most distinctive stage; lasts 2-4 weeks
• Paroxysms of coughing during expiration
• Forceful inhalation “whoop”
• http://www.pkids.org/diseases/pertussis.html
• Post-tussive emesis
Convalescent – resolution of symptoms; lasts 1-2 weeks
• Coughing becomes less severe; whoops disappear
• Residual cough may last for months
Clinical Manifestations: Pertussis
Infants: not classic**
Apnea (can hypoxia leading to CNS damage)
No classic “whoop”
Secondary bacterial pneumonia common
Adolescents/adults: not classic**
Prolonged bronchitis-like illness
Persistent, nonproductive cough
Begins as nonspecific URI
Generally do not have “whoop”, but will have paroxysms
of cough
Cough lasts weeks-months
Diagnosis**
Definitive diagnosis based on culture of B.
pertussis from nasopharyngeal specimen
VERY difficult to isolate
DFA of nasopharyngeal secretions
Technically difficult; low sensitivity (~60%)
PCR is the preferred method
More sensitive and specific
CBC: marked leukocytosis and lymphocytosis
Treatment**
Age < 6 months: strongly consider admit
Close monitoring (cyanosis, apnea), frequent suctioning,
O2, IVFs, nutrition
Antibiotics
1st line: macrolide
2nd line: TMP-SMX
Early treatment (catarrhal stage) eradicates
nasopharygeal carriage, shortens duration of illness
However, treatment during the paroxysmal stage does
NOT alter the clinical course
• Does reduce the spread of secondary cases
Can return to school after treatment x 5 days
Treatment
Prophylaxis**
ALL close contacts should receive prophylaxis
(including child care/school contacts)
Antibiotics
• Same agents, dose, duration as for treatment of pertussis
• Best if within 21 days of onset of cough in index case
Immunization
• Close contacts who are unimmunized or underimmunized should
also have pertussis vaccine initiated or continued immediately
• DTaP: for children <7 years old
• Tdap: for children ages >7 years old
Routine Pertussis Vaccine
Recommendations
DTaP: 5 doses
2months, 4months, 6months, 15-18months, 4-6years
Tdap: 1 dose
11-12years
Immunization with Tdap (if not received previously) is
recommended for adults who will have close contact with
an infant aged <12 months (at least 2 weeks prior to
contact with the infant)
Contraindications for pertussis vaccine**:
Allergic reaction, unstable or active CNS disease, encephalopathy
within 7 days of receiving prior pertussis vaccine
Waning Immunization**
Neither infection with active disease or vaccination
provides complete or lifelong immunity
Protection begins to wane 3-5 years after vaccination
No discernable immunity after 12 years
THANK YOU!!
Noon conference: Residents as Teachers
(Dr. English)
Students off!!