NYU Medical Grand Rounds Clinical Vignette Christopher Schultz, MD, PGY-2 February 24, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

A 53-year-old man presents with fever, cough and malaise for ten days. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS The patient was in his usual state of good health until three weeks prior to presentation, when he was reunited with his 11-year-old son who had been away at camp. The son had returned home with malaise and a non- productive paroxysmal cough associated with vomiting. The boy’s illness persisted for one week and resolved without treatment. The child had no fever throughout his illness and was reported to have received all routine age-appropriate childhood vaccinations.

History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS One week prior to presentation, the patient began to experience malaise and cough. Over the next four days, the patient’s condition did not improve, and he began experiencing fever, head ache and chest pain in addition to his original symptoms. He presented for further evaluation.

Additional History U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Past Medical History None Unknown vaccinations Past Surgical History None Family History Mother: diabetes mellitus Social History Born in Bermuda Divorced Lives with son One bedroom apartment Lifetime non-smoker Social alcohol use Denies illicit drug use

Outpatient Medications U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS None Allergies: None

Physical Examination U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS General: Well-appearing man in no acute distress, experiencing occasional cough Vitals: T 100.7, BP 125/85, HR 85, RR 14 O 2 saturation: 98% on room air The remainder of the physical exam was normal.

Initial Studies U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS CBC: White blood cell count 16,000 Lymphocytic predominance The remainder was within normal limits Basic Metabolic Panel: Within normal limits Hepatic Panel: Within normal limits

Imaging U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Chest X-Ray Mild bilateral basilar atelectasis No consolidation or effusions noted

Initial Studies U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Sputum Gram Stain: Large numbers of polymorphonuclear leukocytes Some gram-negative coccobacilli. Sputum culture was collected.

Working diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Bronchitis

Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS The patient was prescribed ampicillin-clavulanic acid, but his symptoms persisted. Growth from the patient’s sputum culture was consistent with a normal respiratory biota. Two weeks into the patient’s illness, he developed paroxysmal coughing with occasional vomiting. These paroxysms increased over several weeks, and persisted for over one month.

Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS During his prolonged clinical course, the patient underwent additional serologic testing at a follow-up visit. IgG and IgA antibody titers to filamentous hemagglutinin and pertussis toxin were obtained and markedly elevated. Two weeks later, the patient’s coughing paroxysms finally resolved.

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Final Diagnosis Acute Bordetella pertussis infection transmitted through a previously immunized child presenting with atypical disease Case report modified from: Smith S and RC Tilton. Journal of Clinical Microbiology 1996; 34:

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