Transcript Staff Conference

July 16, 2008
Melissa Mae P. Baluyot, MD
Pertussis on the rise?
 waning immunity among vaccinated individuals,
who become susceptible during adolescence and
adulthood
 duration of pertussis vaccine-induced immunity:
vaccinated adolescents and adults become
susceptible to pertussis about 5–10 years after
vaccination.
Objectives
 Discuss pertussis presenting in an infant
 Review the recent updates in the diagnosis,
treatment and prophylaxis of pertussis
 Review the recent guidelines on pertussis
vaccination.
General Data
 C.A.
 7 wks/female Filipino
 Roman Catholic
 from Muntinlupa City
 admitted for the first time in PGH
 Date of admission: February 23, 2008
Chief Complaint
 Cough
 Difficulty of breathing
 Cyanosis
History of Present Illness
 full term via SVD
 25 y/o G2P1 (1001) mother
 Prenatal check-up c/o local health center
 (-) maternal illness
 (-) fetomaternal complications
 At birth, (+) good suck and activity.
History of Present Illness
2 weeks PTA
(+) cough associated
with tachypnea,
grunting and circumoral
cyanosis
triggered by coughing.
(-) fever, (+) good suck
No consult was done nor
medications given.
History of Present Illness
1 week PTA
(6th week of life)
persistence of cough
consult with a private
MD
A> URTI
P> Amoxicillin
(unrecalled dose) x 1wk
Persistence of cough
(+) circumoral cyanosis
ADMISSION
Review of Systems
 (+) poor suck
 (-) fever
 (-) jaundice
 (-) vomiting
 (-) diarrhea
 (-) seizures
 Past Medical History: as above
 Family Medical History: (-) similar illness,
(-) Bronchial Asthma, (-) Pneumonia,
(-) Pulmonary Tuberculosis
(-) Diabetes Mellitus , (-) Cancer
 Immunizations: (-) BCG, (-) Hepa B, (-) DPT
(-) OPV
 Nutritional History: breastfed exclusively
up to 1 month, then formula fed thereafter
 Personal Social History: Patient is the younger
of 2 children. Mother is a 25 y.o. housewife.
Father is 27 y.o. tricycle driver.
Physical Examination at the ER
 General exam
 Vital signs
 Anthropometrics
 Skin
Awake in mild respiratory
distress
BP 80palp HR 160
RR 60s
Temp 37 ˚C
Lt 49 cm (<p5)
Wt 3.5 kg (<p5) HC 36 cm
CC 37 cm AC 36 cm
warm moist, good skin
turgor, no jaundice
Physical Examination at the ER
 HEENT
 Chest
normocephalic, anterior fontanel soft
and flat, pink palpebral conjunctivae,
anicteric sclerae, (-) conjunctival
hemorrhages, (-) cervical lymph nodes
(-) tonsillopharyngeal congestion/
exudates
symmetric chest
expansion, (+) subcostal, intercostal
retractions, (+) crackles both lung fields
Physical Examination at the ER
 Cardio
 Abdomen
 Extremities
adynamic precordium,
distinct heart sounds,
normal rate regular rhythm,
(-) murmurs
globular, normoactive bowel
sounds, soft, no palpable mass no
organomegaly
pink nail beds, full and equal
pulses, (-) cyanosis/edema
Neurologic Examination
 General Survey
 Cranial Nerves
 Motor
 DTRs
 Other reflexes
 Meningeals
Awake, irritable
pupils 2-3 mm EBRTL
(+) brisk corneals (+) gag
reflex
moves all extremities
spontaneously
++ on all extremities
(+) Babinski bilateral,
(+) Moro, sucking reflexes
(-) nuchal rigidity,
(-) Brudzinki
Salient Features
 2 week-history of cough
 not relieved despite intake of Amoxicillin
 tachypnea, circumoral cyanosis triggered by
coughing, and poor suck
 in mild respiratory distress
 tachypneic with RR 60s T 37 ˚C
 symmetric chest expansion, subcostal and
intercostal retractions, and crackles on both lung
fields.
Clinical cues
 age of symptom onset (i.e. duration of cough)
 quality of the cough
 triggers, periodicity and timing of cough
 associated features such as wheezing
CHARACTERISTIC
THINK OF
Staccato, paroxysmal
Pertussis, cystic fibrosis, foreign body,
Chlamydia spp., Mycoplasma spp.
Followed by “whoop”
Pertussis
All day, never during
sleep
Psychogenic, habit
Barking, brassy
Croup, psychogenic, tracheomalacia,
tracheitis, epiglottitis
Hoarseness
Laryngeal involvement (croup, recurrent
laryngeal nerve involvement)
Abrupt onset
Foreign body, pulmonary embolism
Follows exercise
Reactive airways disease
Accompanies eating,
drinking
Aspiration, gastroesophageal reflux,
tracheoesophageal fistula
Throat clearing
Postnasal drip
Productive (sputum)
Infection
From Kliegman RM, Greenbaum LA, Lyle PS: Practical Strategies in Pediatric Diagnosis and Therapy, 2nd ed. Philadelphia, Elsevier Saunders, 2004, p 19.
Night cough
Sinusitis, reactive airways disease
Seasonal
Allergic rhinitis, reactive airways disease
Immunosuppressed
patient
Bacterial pneumonia, Pneumocystis carinii,
Mycobacterium tuberculosis,
Mycobacterium avium–intracellulare,
cytomegalovirus
Dyspnea
Hypoxia, hypercarbia
Animal exposure
Chlamydia psittaci (birds), Yersinia pestis
(rodents), Francisella tularensis (rabbits), Q
fever (sheep, cattle), hantavirus (rodents),
histoplasmosis (pigeons)
Geographic
Histoplasmosis (Mississippi, Missouri, Ohio
River Valley), coccidioidomycosis
(southwest), blastomycosis (north and
midwest)
Workdays with
clearing on days off
Occupational exposure
C.A.
 cough – continuous
 episodic
 circumoral cyanosis and tachypnea
Course at the PER
Course at the PER
 Initial CBC showed leukocytosis of 36.8.
 Initial impression: Pneumonia community
acquired rule out neonatal sepsis
Course at the PER
 Lumbar tap – CSF GS/CS: no organism/growth
 Ampicillin (200) and Amikacin (15)
 Salbutamol nebulization was done
 O2 support via funnel
Course at the PER
 After day 3 of antibiotics
– not noted to be improving
– still had cough and tachypnea
– decked for ward admission
Course in the Wards
 (+) cough, (+) tachypnea, (+) subcostal retractions
and circumoral cyanosis during coughing episodes
 Repeat chest x-ray showed increased infiltrates
 Assessment: Pneumonia, Community acquired
progressing with atypical component.
 Plan:
 Ampicillin shifted to Cefuroxime (100)
 Amikacin (15) continued and Clarithromycin (15) started
 O2 support and Salbutamol nebulization were
continued.
Course in the Wards
 8th hospital day
 (Day 3 of new antibiotics)
– still had cough, subcostal retractions
– increasing WBC to 43.8 still with predominance
of lymphocytes
Course in the Wards
– Assessment: Nosocomial pneumonia
– Plan: Cefuroxime shifted to Ceftazidime (100).
Chronic cough
 cough of > 4 weeks duration (Guidelines for Evaluating
Chronic Cough in Pediatrics American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines)
 varies from 3 weeks to 12 weeks in duration.
 no studies that have clearly defined when cough
should be defined as chronic or persistent.
Persistent Cough
 Hypersensitivity of cough







receptors after infection
Reactive airways disease
(asthma)
Chronic sinusitis
Bronchitis, tracheitis due to
chronic infection, active or
passive smoking
Bronchiectasis, including cystic
fibrosis, primary ciliary
dyskinesia, immunodeficiency
Foreign body aspiration
Recurrent aspiration owing to
pharyngeal incompetence,
tracheolaryngoesophageal cleft,
tracheoesophageal fistula
Gastroesophageal reflux, with or
without aspiration
 Pertussis syndrome
 Extrinsic compression of the








tracheobronchial tract (vascular
ring, neoplasm, lymph node,
lung cyst)
Tracheomalacia,
bronchomalacia
Endobronchial or endotracheal
tumors
Endobronchial tuberculosis
Habit cough
Hypersensitivity pneumonitis
Fungal infections
Inhaled irritants, including
tobacco smoke
Irritation of external auditory
canal
Reactive airways disease (asthma)
 persistence of cough, tachypnea and retractions
 accompanied by occasional wheezes, tight airways
and persistently thick secretions
 (-) family history of asthma, or any other atopic
disease
 lack of improvement despite Salbutamol and
Combivent nebulization
 At the time that reactive airway disease was
considered, the service planned to start patient on
Prednisone. Patient was then referred to Pulmo
service.
Gastroesophageal reflux
 Vomiting
 post-tussive vomiting, poor suck and no signs of
failure to thrive
 Erythromycin (30) and Famotidine (0.8) were
started and the plan was to do an upper GI series.
 In literature, infantile reflux was noted to manifest
more often with regurgitation (especially
postprandially), signs of esophagitis (irritability,
arching, choking, gagging, feeding aversion), and
resulting failure to thrive.
Endobronchial tuberculosis
 paroxysmal cough ending in cyanosis
 no exposure to PTB
 CXR did not show lymph node enlargement or
opacity
 Crepitant rales and expiratory wheezes
 moderately high fever, anorexia, night sweats, loss
of weight
Course in the Wards
 14th hospital day – seen by Pulmo service
regarding assessment of hyperreactive airways and
plan of starting Prednisone.
 Assessment: to consider new onset nosocomial
pneumonia
 Plan: Cefexime oral shifted to Meropenem (60) IV
Course in the Wards
 15th hospital day- seen by IDS service
 salient points contributing to the patient’s final
diagnosis:
 7 week/F
 Cough of ≥14 days duration with associated post-tussive




vomiting
Tachypnea and circumoral cyanosis
No immunizations
Leukocytosis with persistently predominant
lymphocytes
Negative blood and CSF cultures
LABS DONE
CBC
2/23 2/29 3/5
3/8
3/12
Hgb
Hct
WBC
105 114 107 115 104
0.34 0.36 0.33 0.36 0.387
36.85 43.8 35.9 31.11 13.4
Neut
Lymph
Mono
Eos
Baso
Stabs
Platelets
36
48
11
1
4
437
29
57
13
24
55
11
28
58
14
40.7
41.1
12.6
2.6
3
873
912
904
219
WHO Case Definition
 Cough at least 2 weeks with at least one of the
following symptoms:
 Paroxysms (i.e. Fits) of coughing
 Inspiratory “whooping”
 Post-tussive vomiting (i.e. Vomiting
immediately after coughing) without apparent
cause
WHO Case Definition
 Criteria for laboratory confirmation
 Isolation of Bordetella pertussis
 Detection of genomic sequences by PCR
 Positive paired serology
 Case Classification
 Clinical case: A case that meets the clinical case
definition but is not laboratory confirmed
 Laboratory confirmed case: A case that meets
the clinical case definition and is laboratory
confirmed
Natural History of the Disease
 incubation period - between 6 and 21 days
typically 6–10 days
 catarrhal phase - lasts 1–2 weeks
patients are most contagious
 paroxysmal phase - lasts 3–6 weeks
characterized by spells of
coughing with the characteristic
whoop, vomiting, cyanosis and
apnea
Clinical Presentation of Pertussis in Unvaccinated and
Vaccinated Children in the First Six Years of Life
Alberto E. Tozzi, Lucilla Ravà, Marta L. Ciofi degli Atti, Stefania Salmaso and the Progetto Pertosse Working Group
Pediatrics 2003;112;1069-1075
 the clinical course was independent of age and sex
until the age of 3
 after this age, the duration of spasmodic cough
was 7 days longer among girls than among boys
and decreased with age, and the duration of cough
increased.
Clinical Presentation of Pertussis in Unvaccinated and
Vaccinated Children in the First Six Years of Life
Alberto E. Tozzi, Lucilla Ravà, Marta L. Ciofi degli Atti, Stefania Salmaso and the Progetto Pertosse Working Group
Pediatrics 2003;112;1069-1075
 children under 6 months of age do not develop
paroxysmal cough or the characteristic inspiratory
whoop. Instead, recurrent episodes of apnea,
cyanosis and bradycardia can dominate the clinical
picture in infants, and a prolonged and
complicated course is often observed.
Laboratory Findings
 mild increase in the leukocyte count and marked
lymphocytosis are classic markers of pertussis
 C.A. had a consistently lymphocytic predominant
differential count.
Laboratory Findings
 Culture – nasopharyngeal secretions are collected
through swabbing or aspiration
 C.A.’s nasopharyngeal aspirate was negative
 Positive predictive value of culture is 100%
- sensitivity is highest in the early stage of
infection, before the natural clearance of
bacteria, in severe cases, in unvaccinated
patients and in infants.
Laboratory Findings
 The likelihood of a positive result may be
negatively affected by antibiotic treatment
 Therefore, our patient’s aspirate was probably
negative due to delayed acquisition of specimen
that is, antibiotic treatment has been started.
Course in the Ward
 Meropenem was discontinued
 Erythromycin increased to 40mkd to be completed
for 14 days.
ALTERNATE AGENT[*]
PRIMARY AGENTS
AGE
GROUP
<1 mo
Azithromycin
Erythromycin
Clarithromycin
TMP-SMZ
Recommended agent. 10
mg/kg/day in a single dose
for 5 days (only limited
safety data available)
Not preferred.
Erythromycin is
associated with
infantile
hypertrophic pyloric
stenosis.
Not recommended
(safety data
unavailable)
Contraindicated for infants
aged <2 mo (risk for
kernicterus)
40–50 mg/kg/day in
4 divided doses for
14 days.
15 mg/kg/day in 2
divided doses for 7
days
Contraindicated at age <2
mo For infants aged ≥2 mo.
Use if azithromycin
is unavailable; 40–
50 mg/kg/day in 4
divided doses for 14
days.
1–5 mo
10 mg/kg/day in a single
dose for 5 days
TMP 8 mg/kg/day, SMZ 40
mg/kg/day in 2 divided
doses for 14 days
Infants
(aged ≥6
mo) and
children
10 mg/kg in a single dose
on day 1 then 5 mg/kg/day
(maximum 500 mg) on
days 2–5
40–50 mg/kg/day
(maximum 2 g/day)
in 4 divided doses
for 14 days.
15 mg/kg/day in 2
divided doses
(maximum 1 g/day) for
7 days
TMP 8 mg/kg/day, SMZ 40
mg/kg/day in 2 divided
doses for 14 days
Adults
500 mg in a single dose on
day 1 then 250 mg/day on
days 2–5
2 g/day in 4 divided
doses for 14 days.
1 g/day in 2 divided
doses for 7 days
TMP 320 mg/day, SMZ
1,600 mg/day in 2 divided
doses for 14 days
Complications
 Pneumonia- most frequent
occurs in 6% of cases
 Sinusitis
 otitis media
 viral and bacterial superinfections
 nutritional deficiencies resulting from repeated
vomiting
 neurologic complications
Complications
 Assessment: Aspiration pneumonia
 Plan: started on Co-amoxiclav (40).
Course in the Ward
 20th hospital day
 feeding well
 no recurrence of cyanosis and tachypnea
 Home meds: Erythromycin (40) x 14 days and
Co-amoxiclav (40) x 7 days.
 follow-up at IDS clinic, Pulmo clinic, and
Continuity clinic
 vaccines were updated
Immunization
one of the most cost-effective preventive
measures
smallpox has been eradicated
polio is close to worldwide eradication
measles and rubella are no longer endemic
in the U.S.
Pertussis caught recent attention among
experts because of a changing epidemiology
in recent decades.
Pertussis Immunization
 introduction in the 1940s
 prevaccine rate of almost 200 000 cases annually to a
historic low of 1010 cases in 1976
 belief was pertussis immunization conferred lifelong
immunity
 since the 1980s, despite high levels of routine
childhood immunization for pertussis, the number of
reported cases has increased steadily among young
infants and among adolescents and adults
Trend in Pertussis
 Two peaks in the incidence
 infants younger than 6 months of age
 adolescents 11 through 18 years of age
 Adolescents are reservoirs of B pertussis
and can be sources of pertussis for young infants,
who have the highest risk of pertussis-related
complications, hospitalization, and death.
AAP Recommendations
 Adolescents 11 to 18 years of age should receive a single
dose of Tdap instead of tetanus and diphtheria toxoids
(Td) vaccine for booster immunization. The preferred
age for Tdap immunization is 11 to 12 years.
 Adolescents 11 to 18 years of age who have received Td
but not Tdap are encouraged to receive a single dose of
Tdap. An interval of at least 5 years between Td and
Tdap is suggested to reduce the risk of local and
systemic reactions
AAP Recommendations
 Tdap and tetravalent meningococcal conjugate vaccine
(MCV4 [Menactra]) should be administered during
the same visit if both vaccines are indicated. If this is
not feasible, MCV4 and Tdap can be administered
using either sequence. When not administered
simultaneously, the AAP suggests a minimum interval
of 1 month between vaccines.
Conclusion
 Increase in frequency of pertussis cases
 Pertussis immunization does not confer lifelong
immunity
 Pertussis is an important differential diagnosis
 A diagnosis of pertussis can be made with a detailed
history and physical exam
 Adolescents 11 to 18 years of age should receive a single
dose of Tdap instead of tetanus and diphtheria toxoids
(Td) vaccine for booster immunization.
Thank You