Case Based Presentation Sian Chess-Williams

Contents Case: history, examination & investigations Diagnosis & Management. Vaccine Conclusion References

History A&E admission 2 month old girl PC – spasmodic cough 1/52 HPC: becomes purple/red in face with cough and vomiting after coughing 4/7. “struggles to catch breathe”. Also has been snuffley. No apnoea or cyanosis. No fever. Passing urine fine. Bowels fine. Feeding well 210ml 3-4 hourly (275ml/kg/day)

History Birth Hx / PMH: Term + 10, induced NVD FH: mum & daughter have had cough & cold. SH: lives with mum, dad, 3 siblings (age 1, 3, & 4 years) – not had imms Immunisations: not had any yet Development: no worries Medication: nil, no allergies.

Examination Temp 36 ⁰C, RR 38, HR 162, Sats 96% air Alert & active Chest clear, no respiratory distress HS 1+2+0, cap refill < 2 secs, femorals ++ Abdo soft, no hepatosplenomegaly Anterior fontanelle normotensive Mucous membranes moist Good tone, sucking & grasping reflexes present. No rash / bruising.

Investigations Nasal swab NPA SATs monitor Oral Erythromycin Decrease feeds from 7 to 5 oz CXR Bloods FBC, U&E, CRP NG feeds

Investigations Nasal swab NPA: RSV negative SATs monitor (drop to 74% during a paroxysm of coughing). Oral Erythromycin Decrease feeds from 7 to 5 oz CXR: NAD Bloods: WCC 34, lymphocytes 21.7, CRP < 1 NG feeds

Whooping cough Bacterium Bordetella pertussis. Most infectious during the prodromal phase (coryza) & is infectious for up to 3 weeks. Affects any age, but infants less than 6 months are at the greatest risk of complications. Mortality: 1 in 200 if < 6 months old.

Whooping cough Prodromal phase – nasal discharge & cough lasting a few days. Paroxysmal phase - Prolonged paroxysms of coughing +/- vomiting and terminated by a characteristic inspiratory whoop. Complications: apnoea, severe pneumonia, encephalopathy, death

Management Hospital admission for supportive therapy if needed. Macrolide antibiotics (erythromycin) reduce the period of infectivity. Avoid creche, school, ect until had at least 5 days of Abx or had illness for at least 21 days. Household contacts also treated to reduce spread of infection. Notifiable disease

Vaccine Incidence and severity is greatly reduced by the pertussis vaccine. Increased herd immunity reduces transmission to young babies from older siblings and adults. Diphtheria/tetanus/acellular pertussis/inactivated polio vaccine/Haemophilus influenzae type b (DTaP/IPV/Hib) This Pediacel® vaccine contains 5 purified pertussis components of the Bordetella Pertussis organism.

Vaccine Vaccine side effects: minor local reaction (swelling, redness, discomfort) in 15% of recipients. Do not give if past history of anaphylactic reaction to previous pertussis containing vaccine, neomycin, streptomycin or polymyxin B. Risk of anaphylactic reaction <3 per million doses. Do not give if child has an evolving neurological condition or current neurological deterioration.

Vaccine From the mid-1990s, uptake has consistently been over 90%. In 2008 there were 244 cases of whooping cough reported between April and June.

Conclusion Whooping cough is preventable. It can have serious complications including death. Management is only supportive. The majority need to be vaccinated to help protect those too young to be vaccinated.

Any questions

References Bohlke K, Davis RL, Marcy SM, et al; Risk of anaphylaxis after vaccination of children and adolescents. Pediatrics Oct;112(4): [abstract] Miller E; Overview of recent clinical trials of acellular pertussis vaccines. Biologicals Jun;27(2): [abstract] HPA - Whooping Cough (Pertussis). Health Protection Agency. Patient UK website: vaccines. D. M. Roberton, M South;Practical paediatrics. Sixth edition