Transcript 84 yo woman with a cough: epidemiologic implications

84 yo woman with a cough
Mary H. Pak, M.D., FACP
Primary Care Conference
February 22, 2006
Disclosure
Received honorarium for being on an
advisory panel for Pfizer related to
linezolid.
Case presentation
• EG is an 84 yo woman who presented to the
ER with a cough of 1-2 weeks in duration.
– She notes some shortness of breath, mostly
related to the coughing fits as well as intermittent
chest pains.
– There is no sputum production.
– She has had difficulty sleeping because of the
coughing.
– She has some nausea related to the cough but no
emesis.
Case presentation (con’t)
• PMH:
Metastatic renal cell CA (treated in
eastern Europe, s/p
nephrectomy 6 years ago)
Hypertension
Arthritis
Depression
Case presentation (con’t)
Medications:
captopril 50 mg po b.i.d.
Ambien prn
Robitussin (OTC)
Tylenol prn
Allergies: Morphine  nausea
SH/FH: widowed, lives with daughter in
Madison. Denies any tobacco or alcohol
use. FH heart disease, no other cancers. No
information about her immunization history.
Case presentation (con’t)
ROS:
No fevers, chills or sore throat
No sputum production or
hemoptysis
No known sick contacts
Irritated and itchy eyes occasionally
Diffuse arthralgias
Case presentation (con’t)
Physical Examination
– T 98.9, BP 145/64, pulse 70, resp 16, 95% RA
– Lungs were clear to auscultation B/L
– Heart was regular in rhythm with no
appreciable gallops, murmurs or rubs
– Extremities were noted to have trace ankle
edema with negative Homan’s sign
Case presentation (con’t)
Laboratory data:
• WBC 8.1 (normal diff), H/H 11.5/33, plt 285
• Normal electrolytes, creatinine 1.7, BUN 40
• BNP 175
• Troponin 0.1
• D-dimer 0.6
Case presentation (con’t)
• Differential diagnosis:
 viral URI (including RSV, adenovirus) or URI
symptoms related to Influenza type virus
 atypical respiratory infections including
Mycoplasma pneumoniae, Chlamydia
pnueumoniae, Bordetella pertussis, Bordetella
parapertussis
 Cough secondary to post nasal drip
 GERD
Case presentation (con’t)
• We sent off a nasopharyngeal swab for
Bordetella pertussis DNA PCR and culture
• Placed the patient in respiratory droplet
isolation
• Started azithromycin 500 mg
Objectives
• Case presentation
• Differential diagnosis of prolonged cough
• Discussion regarding epidemiology,
diagnosis and treatment of pertussis
• Role of adult vaccination
Bordetella pertussis: epidemiology
• 25,827 cases reported in the U.S in 2004
 60% cases in adolescents (11-18) and adults (>20)
• Transmitted from person-to-person through
aerosolized respiratory droplets from cough or
sneeze or direct contact with secretions from
infected persons.
• Incubation period 5 – 21 d (typical 7 – 10d)
• Endemic in U.S., epidemic every 3 - 4 years.
Tiwari T, MMWR 2005
MMWR 54 (50), 1284
MMWR 54 (50), 1285
Bordetella pertussis: economics
• Pertussis in adults has been shown to
generate medical and nonmedical costs of
$773 per case-patient.
• Often leads to 10 days of missed work.
Lee GM, Clin Inf Dis 2004
Bordetella pertussis
• Uniquely human pathogen
• Only disease for which universal childhood
vaccination is recommended that has an
increasing trend in reported cases in U.S.
 In early vaccine years (1920 – 40), average
annual rate 150 per 100,000 population
 After universal vaccination during 1940’s,
declined to 1 case per 100,000.
 In 2004, 8.4 cases per 100,000
Robbins JB, Clin Inf Dis 1999
Tiwari T, MMWR 2005
Bordetella pertussis: clinical
manifestations
• Catarrhal period (1 – 2 weeks)
 Coryza, mild fever, non productive cough
 Infants can have apnea and respiratory distress
• Paroxysmal period (2 – 6 weeks)
 Paroxysmal cough, inspiratory “whoop”,
posttussive vomiting
• Convalescent period (> 2 weeks)
Tiwari T, MMWR 2005
Bordetella pertussis: clinical
manifestations
• Potential complications:
– Weight loss (due to coughing)
– Sleep disturbance
– Effects generated by increased pressure due to
severe coughing including pneumothorax,
epistaxis, subconjunctival hemorrhage, subdural
hematoma, rib fracture, urinary incontinence.
– Secondary bacterial pneumonia including
aspiration pneumonia related to posttussive
vomiting
Dworkin MS, Ann Intern Med 2005
Tiwari T, MMWR 2005
Bordetella pertussis: testing
• Culture of the nasopharyngeal mucus is the
“gold standard”
 Prefer aspiration samples via hand-trap
 If swabs are to be used, Dacron is
recommended since alginate may inhibit PCRbased assays and cotton may be toxic to the
bacteria.
• Send for B. pertussis PCR and culture.
Dworkin MS, Ann Intern Med 2005
Bordetella pertussis: diagnostic
barriers
• Reluctance to cause patient discomfort
• Need for special transport medium (BordetGengou medium)
• Tendency for the organism to die before culture
confirmation
• Low yield of PCR and culture in the setting of
partial immunity
• Chronicity of cough delays diagnosis to a time
when diagnostic yield is poorest.
• Lack of reliable serologic markers
Dworkin MS, Ann Intern Med 2005
Testing for pertussis is not sufficiently
sensitive for treatment decision to be guided
by test results alone.
Bordetella pertussis: treatment
Tiwari T, MMWR 2005
Bordetella pertussis: vaccination
• In May, 2005, Boostrix (GlaxoSmithKline)
was licensed for vaccination in persons
between the ages of 10 – 18.
• In June, 2005, Adacel (Sanofi-Aventis) was
licensed for use in person between 11 – 64
years.
• Both vaccines are Tdap vaccines which
contains tetanus, diphtheria and acellular
pertussis.
MMWR 2005; 54 (50)
Bordetella pertussis: vaccination
• On June 30, 2005, the Advisory Committee
on Immunization Practices (ACIP)
recommended a single dose of Tdap for all
persons aged 11 – 18 years.
• In October, 2005, ACIP recommended a
single dose of Tdap for adults aged 19 –64.
• No adoption into immunization guidelines
as yet.
Conclusion
• Pertussis is not solely a childhood disease. Pertussis
is a “community-acquired disease of all ages”
• Reported cases of pertussis has been rising
significantly particularly in the adolescents and
adults.
• Diagnostic testing is not always reliable. Presumptive
treatment with a macrolide is recommended.
• Additional vaccinations in adulthood might help to
decrease the reservoir of pertussis.
References
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2)
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7)
Dworkin MS. Adults are Whooping, but Are Internists Listening?
Ann Intern Med 2005; 142: 832-835.
Tiwari T, Murphy TV, Moran J. Recommended Antimicrobial Agents
for the Treatment and Postexposure Prophylaxis of Pertussis: 2005
CDC Guidelines. MMWR 2005; 54 (RR-14): 1- 15.
Pertussis – United States, 2001 – 2003. MMWR 2005; 54 (50):
1283-1286.
Cherry JD. Epidemiological, Clinical and Laboratory Aspects of
Pertussis in Adults. Clin Inf Dis 1999; 28 (Suppl 2): S112-S117.
Keitel WA. Cellular and Acellular Pertussis Vaccines in Adults. Clin
Inf Dis 1999; 28 (Suppl 2): S118-S123.
Gardner P. Indications for Acellular Pertussis Vaccines in Adults: The
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Dis 1999; 28 ( Suppl 2): S131-S135.
Orestein WA. Pertussis in Adults: Epidemiology, Signs, Symptoms
and Implications for Vaccination. Clin Inf Dis 1999; 28 (Suppl 2)
S147-S150.
References (con’t)
8)
9)
10)
Ward JI, et al. Efficacy of an Acellular Pertussis Vaccine among
Adolescents and Adults. N Eng J Med 2005; 353: 1555-1563.
Robbins JB. Pertussis in Adults: Introduction. Clin Inf Dis 1999; 28
(Suppl 2): S91-93.
Hewlett EL. A Commentary on the Pathogenesis of Pertussis. Clin
Inf Dis 1999; 28 (Suppl 2): S94-S98.