1. Pertussis Kate Goheen March 25, 2009 Weill Cornell Medical College Class of 2010

2. Case Presentation 4 m.o. male with h/o Klinefelter Syndrome, bilateral hip dysplasia and club feet CC: cough and difficulty breathing HPI: mild cough for one week, worsening, with one 10-second episode of coughing and cyanosis which prompted mother to come to ER ER: mild respiratory distress, wheezing and retractions T 99.1 HR 152 RR 66 O2 sat 99% Plan: admit to 4B for bronchiolitis

3. Hospital Course HD#1 Patient started on albuterol Q2 One witnessed episode of coughing and cyanosis <10 seconds Nebs changed to racemic epinephrine and levalbuterol DFA and cx sent for pertussis Started on azithromycin

4. Hospital Course Cont’d HD#2 Febrile to 101.3 CXR showed RLL infiltrate, WBC 15.1 (N32%, L59%) Cefuroxime added Levalbuterol maintained Q6 HD#4 DFA and cultures negative Discharged to home on cefuroxime and azithromycin

5. What is Pertussis? Whooping cough, “The Cough of 100 Days”

6. Infants are at high risk of complications Preventing Tetanus, Diphtheria, and Pertussis Among Adults: Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine. Kretsinger, Katrina et al. MMWR Recommendations and Reports December 15, 2006 / 55(RR17);1-33. Infants accounted for 92% of US pertussis deaths in 2000-2004.

7. Annual Reported of Cases of Pertussis in the US, 1922-2003 Pertussis- Not Just for Kids. Hewlett, Erik and Edwards, Kathryn. NEJM 352;12 March 24, 2005, p. 1215-1224.

8. Spread of Pertussis: Then vs. Now

9. Increased awareness and reporting Better tests Waning immunity in adults Why is the Incidence of Pertussis Increasing?

10. Immunized kids also get pertussis DTDTaP Cough (days)61*29-33 Apnea (%)84.5*36-47 Cyanosis (%)64.9*21-31 Vomiting (%)85.6*56-58 Clinical presentation of pertussis in unvaccinated and vaccinated children in the first six years of life. AU Tozzi AE; Rava L; Ciofi degli Atti ML; Salmaso S SO. Pediatrics 2003 Nov;112(5):1069-75. *P <.001 Clinical Presentation of Pertussis by Vaccine Group in Infants 6-24 Months Old

11. Pertussis is milder in immunized adults and adolescents Persistent cough can be the only symptom Whooping in 20-40% Post-tussive emesis in about half “Scratchy throat” in 33% Sweating episodes in 40- 50% pts over 30 y.o. 13-32% of adults with cough >6 days have serologic evidence of B. pertussis infection Preventing Tetanus, Diphtheria, and Pertussis Among Adults: Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine. Kretsinger, Katrina et al. MMWR Recommendations and Reports December 15, 2006 / 55(RR17);1-33.

12. Diagnosis and Treatment Pertussis can only be recovered in first 3-4 weeks of illness, very hard to culture Do culture and PCR Tx: 5 days of azithromycin for patients and contacts Centers for Disease Control and Prevention. Recommended antimicrobial agents for the treatment and postexposure prophylaxis of pertussis. 2005 CDC guidelines. MMWR 2005; 54:10.

13. Vaccine Schedule: Expanded to Adults! DTaP 2, 4, 6 months 15-18 months 4-6 years Tdap 11-12 years One dose between 19- 64 (instead of Td) Any adult in contact with infant <1 y.o.

14. Conclusions Pertussis is still around! Infants have high morbidity and mortality Suspect pertussis in any patient with a prolonged cough, even if vaccinated Encourage parents and grandparents to get Tdap boosters

15. Thank you! Questions? Comments?