Whooping cough

Infectious diseases

Clinicals - History

Fact Explanation
Catarrhal phase:- nonspecific symptoms Symptoms of whooping cough are explained in 3 phases, such as catarrhal, paroxysmal, and convalescent. Bordetella pertussis bacteria produces antigens that can cause local cell damage and may mediate systemic symptoms as well. Symptoms of the catarrhal phase are low-grade fever, malaise due to action of cytokines released to the circulation from the on going inflammation, tearing, red eye and itching of the eye due to mild conjunctival inflammation, rhinorrhea, late-phase nonproductive cough.
This phase has insidious onset and persist for 1-2 weeks with gradually worsening of the symptoms.
Catarrhal phase:- nonspecific symptoms
Symptoms of whooping cough are explained in 3 phases, such as catarrhal, paroxysmal, and convalescent. Bordetella pertussis bacteria produces antigens that can cause local cell damage and may mediate systemic symptoms as well. Symptoms of the catarrhal phase are low-grade fever, malaise due to action of cytokines released to the circulation from the on going inflammation, tearing, red eye and itching of the eye due to mild conjunctival inflammation, rhinorrhea, late-phase nonproductive cough.
This phase has insidious onset and persist for 1-2 weeks with gradually worsening of the symptoms.
Paroxysmal phase:- characteristic cough Patients develop bouts of coughing which is violent in nature during a single exhalation which is followed by an inspiratory whooping sound. These paroxysms are associated with post-tussive vomiting and cyanosis. Infants can have prolonged coughing. Usually this phase lasts 1-6 weeks.
Earlier vaccinated children will present with long-term cough, not cough with violent coughing or whooping attacks as seen in non-vaccinated children making diagnostic difficulties and aid further transmission of the organism within the families, especially to the infants.
Paroxysmal phase:- characteristic cough
Patients develop bouts of coughing which is violent in nature during a single exhalation which is followed by an inspiratory whooping sound. These paroxysms are associated with post-tussive vomiting and cyanosis. Infants can have prolonged coughing. Usually this phase lasts 1-6 weeks.
Earlier vaccinated children will present with long-term cough, not cough with violent coughing or whooping attacks as seen in non-vaccinated children making diagnostic difficulties and aid further transmission of the organism within the families, especially to the infants.
Convalescent phase:- resolution of symptoms Paroxysms resolve slowly, but cough can persist for several months. Convalescent phase:- resolution of symptoms
Paroxysms resolve slowly, but cough can persist for several months.
Poor feeding Found in infants especially neonates. Poor feeding
Found in infants especially neonates.
Difficulty in breathing Since these patients produce a violent cough, they can develop complications like pneumothorax due damage to the pleura following rib fractures, giving rise to difficulty in breathing. Difficulty in breathing
Since these patients produce a violent cough, they can develop complications like pneumothorax due damage to the pleura following rib fractures, giving rise to difficulty in breathing.
History of close contact with a case of whooping cough The causative organism Bordetella pertussis is an exclusively human pathogen that is transmitted via airborne droplets. Therefore history of close contact with the diagnosis of whooping cough may raise the suspicion of whooping cough in the patient also. History of close contact with a case of whooping cough
The causative organism Bordetella pertussis is an exclusively human pathogen that is transmitted via airborne droplets. Therefore history of close contact with the diagnosis of whooping cough may raise the suspicion of whooping cough in the patient also.

Clinicals - Examination

Fact Explanation
Characteristic cough with a whooping sound Pertussis is primarily a toxin-mediated disease, where the bacteria attach to the cilia of the respiratory epithelial cells, produce toxins that paralyze the cilia, and cause inflammation of the respiratory tract, which interferes with the clearing of pulmonary secretions. Most of the time there are no clinical signs between coughing spasms with inspiratory whooping sound which occur with the narroving of the air way. Inspection of the cough is important in diagnosing the condition. Characteristic cough with a whooping sound
Pertussis is primarily a toxin-mediated disease, where the bacteria attach to the cilia of the respiratory epithelial cells, produce toxins that paralyze the cilia, and cause inflammation of the respiratory tract, which interferes with the clearing of pulmonary secretions. Most of the time there are no clinical signs between coughing spasms with inspiratory whooping sound which occur with the narroving of the air way. Inspection of the cough is important in diagnosing the condition.
Apnea Found in infants less than 6 months, especially in neonates as their tiny airways are very much susceptible to occlude completely with little insult. Apnea
Found in infants less than 6 months, especially in neonates as their tiny airways are very much susceptible to occlude completely with little insult.
Bradycardia In neonates heart rate may be slow. Bradycardia
In neonates heart rate may be slow.
Increased body temperature Uncommon sign, may find in few patients. Increased body temperature
Uncommon sign, may find in few patients.
Conjunctival hemorrghages Due to violent coughing. Conjunctival hemorrghages
Due to violent coughing.

Investigations - Diagnosis

Fact Explanation
Culture of a nasopharyngeal swab or an aspirate The causative organism, Bordetella pertussis is very difficult to grow in a culture media. But culture should be done in every patient suspecting whooping cough.
Note: when taking the specimen, nasopharyngeal aspirate is better than a swab in terms of recovering bacteria.
Culture of a nasopharyngeal swab or an aspirate
The causative organism, Bordetella pertussis is very difficult to grow in a culture media. But culture should be done in every patient suspecting whooping cough.
Note: when taking the specimen, nasopharyngeal aspirate is better than a swab in terms of recovering bacteria.
Polymerase chain reaction (PCR) assay Should be done to detect the organism and it is more sensitive than culture later in the disease course and is similar in specificity. Polymerase chain reaction (PCR) assay
Should be done to detect the organism and it is more sensitive than culture later in the disease course and is similar in specificity.
Serology - Direct fluorescent antibody test Even though it confirms the diagnosis quickly, need technically qualified trained personnel to perform. Also its sensitivity is lower compared to PCR assay. Serology - Direct fluorescent antibody test
Even though it confirms the diagnosis quickly, need technically qualified trained personnel to perform. Also its sensitivity is lower compared to PCR assay.
Full blood count Patients found to have leukocytosis and lymphocytosis during paroxysmal phase of whooping cough. During convalescent phase these changes usually normalize. Full blood count
Patients found to have leukocytosis and lymphocytosis during paroxysmal phase of whooping cough. During convalescent phase these changes usually normalize.
Chest X-ray Important to exclude differntial diagnoses and to detect complications. Chest X-ray
Important to exclude differntial diagnoses and to detect complications.

Management - Supportive

Fact Explanation
Parent eduation Parents should be educated properly about the disease condition, possible complications, treatment modalities and the importance of drug compliance. Also should be advised not to send the child to school and presence of others outside the home (especially infants and young children) until received 5 days of therapy, or coughing for more than 21 days. Parent eduation
Parents should be educated properly about the disease condition, possible complications, treatment modalities and the importance of drug compliance. Also should be advised not to send the child to school and presence of others outside the home (especially infants and young children) until received 5 days of therapy, or coughing for more than 21 days.

Management - Specific

Fact Explanation
Hospitallization Most children who developed whooping cough need hospital admission to monitor and detect the complications as soon as possible. Hospitallization
Most children who developed whooping cough need hospital admission to monitor and detect the complications as soon as possible.
Antimicrobial therapy Whooping cough also known as pertussis is caused by gram negative bacterium called Bordetella pertussis. Therefore these patients need antibiotic therapy to reduce risk of transmission, though it has not been shown reduction in disease duration. Erythromycin is the drug of choice and has to be given for 14 days. Other macrolides such as azithromycin and clarythromycin also can be given and known to have less side effects than erythromycin. Antimicrobial therapy
Whooping cough also known as pertussis is caused by gram negative bacterium called Bordetella pertussis. Therefore these patients need antibiotic therapy to reduce risk of transmission, though it has not been shown reduction in disease duration. Erythromycin is the drug of choice and has to be given for 14 days. Other macrolides such as azithromycin and clarythromycin also can be given and known to have less side effects than erythromycin.
Prevention: Chemoprophylaxis Since whooping cough is highly contagious, chemoprophylaxis should be given to close household contacts to control outbreaks. Prevention: Chemoprophylaxis
Since whooping cough is highly contagious, chemoprophylaxis should be given to close household contacts to control outbreaks.
Prevention: Vaccination In United States there is increasing deaths due to whooping cough which can be easily prevented by giving pertussis vaccine. Currently 2 types of vaccines are available- whole cell vaccine with lot of adverse events and the acellular vaccine with a good safety profile though it is less effective than the whole cell vaccine. Currently there are changes in the genome of circulating Bordetella pertussis strains most probably due to use of less effective acellular vaccine world wide, only for young children. Vaccinated programs continued only upto 2 years of age of the child due to increasingly reported adverse events with the whole cell vaccine and less severity of disease in older children.
Protectiveness of the vaccine is short lived and incomplete. Immunity starts to decrease 4-12 years after vaccination, making school children, adolescents and adults susceptible. Therefore not only young children, adolescents and adults also should receive Tdap vaccination in order to reduce the incidence of pertussis and to prevent the disease transmission from adults to infants.
Prevention: Vaccination
In United States there is increasing deaths due to whooping cough which can be easily prevented by giving pertussis vaccine. Currently 2 types of vaccines are available- whole cell vaccine with lot of adverse events and the acellular vaccine with a good safety profile though it is less effective than the whole cell vaccine. Currently there are changes in the genome of circulating Bordetella pertussis strains most probably due to use of less effective acellular vaccine world wide, only for young children. Vaccinated programs continued only upto 2 years of age of the child due to increasingly reported adverse events with the whole cell vaccine and less severity of disease in older children.
Protectiveness of the vaccine is short lived and incomplete. Immunity starts to decrease 4-12 years after vaccination, making school children, adolescents and adults susceptible. Therefore not only young children, adolescents and adults also should receive Tdap vaccination in order to reduce the incidence of pertussis and to prevent the disease transmission from adults to infants.
Monitor and manage complications Associated reported complications of whooping cough are pneumonia, dehydration, weight loss, sleep disturbance, seizures, and, rarely, encephalopathy, refractory pulmonary hypertension or death. Type of complication change according to age of the patient and most victims are infants. Monitor and manage complications
Associated reported complications of whooping cough are pneumonia, dehydration, weight loss, sleep disturbance, seizures, and, rarely, encephalopathy, refractory pulmonary hypertension or death. Type of complication change according to age of the patient and most victims are infants.
Not recommended drugs Antihistamines, steroids, beta agonists, and immunoglobulins are not recommended for routine use for the whooping cough treatment. Not recommended drugs
Antihistamines, steroids, beta agonists, and immunoglobulins are not recommended for routine use for the whooping cough treatment.
Notification Notification is must and important for prevention of the disease. Notification
Notification is must and important for prevention of the disease.
Refer to a paediatrician Indications are infants less than 6 months of age, any child with complications. Refer to a paediatrician
Indications are infants less than 6 months of age, any child with complications.
Transfer to a tertiary care cnetre Any child with complications should be transfered. Transfer to a tertiary care cnetre
Any child with complications should be transfered.

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