Dr Raymond Arhin

HB4 weeks old baby girlPC-Cough and colds-2weeks

Vomiting, apnoeaHPC- Gradual onset of symptoms, bouts of

cough and coryzal symptoms seen GP 2X-Viral infection, Chest infection given Amoxicillin. On day of presentation became blue after coughing bout. Episode lasted about 30 secs.Coughs worse with feeds.No fever, feeding okay, wetting nappies

Pregnancy and developmental historyConception- Twin PregnancyPregnancy was uneventfulNVD at 37+2weeksBirth weight 2.81kgBottle fed SMAImmunisations- awaited

4/52 4/52 8yrs 11yrs

No family history of Asthma, Eczema, Fits or contact with Cough or cold in recent past

ExaminationT 36 C, Pulse 170/min, RR32/min, Sats 92%CVS: HS I & II + Murmur, Liver not palpable,

regular good volume pulses peripherally, CRT<2 secs both centrally and peripherally

CHEST: No signs of resp. distress, good air entry with mild wheeze

ABDOMEN: Soft , No organs palpable, No masses palpable

CNS: Alert, Good tone, No neurological deficits

ENT: Ears clear, Throat normal

DIFFERENTIALSBronchiolitisGORDWhooping CoughCroupPneumoniaCyanotic heart disease

PLANAdmit for observation

Day of AdmissionCyanotic episode lasting about 30 secs

following feeds.Started regular monitoring of saturations.Nurses observed several episodes of

desaturations with and without cough.

Day1Observed to be choking on feeds.Greenish vomit 1X ,copious amountsAssessment: GORD started on GAVISCON5 more episodes of desaturations dropping to 50%-

65% lasting between 10-20 secs.observed to have a loud cough, no resp.distress,

no audible wheeze ,2/6 sysytolic murmurImpression- BronchiolitisInvestigations for FBC, U&E, LFT, CRP, NPA,

Blood c/s,CXR, Blood gas Started on nasal CPAP in view of recurrent

apnoeas

RESULTS

DAY2Continued to have desaturationsCough persistedFeeding reducedStarted on IV FluidsContinued on CPAP

Day3Coughing decreasedRestarted oral feedsMaintaining saturationsExtended NPA

Day4Feeding improvedDesaturations persistedApnoeic episodes worse with Gaviscon so it

was stopped

Day5Twin brother also has a cold and coughFurther history revealed mum did not have

immunisations because she reacted to DPT.Chest- some coarse crepitationsConsider Whooping coughPernasal swabECG

Day6Cough with desaturations getting worse. Saturations drop 60-70%Quick recoveryStarted on Erythromycin in view of persistent

desaturarations

Day7Much more stableDesraturations persist but quick recoveryNo oxygen required

Day8Continued to have coughsNot Requiring any oxygenChest Good Air occasional cracklesFit for dischargeFurther assessment of hart murmur via

TelemedicineDISCHARGED HOME

Cases of whooping cough 'treble'

Monday, 10 March 2008

Cases of whooping cough have nearly trebled since 2003, according to figures from the Department of Health.

The figures were obtained in response to a parliamentary question from the Liberal Democrats health spokesman Norman Lamb.

The figures show that there were 386 cases of whooping cough five years ago compared to 1,071 in 2007.

Whooping cough cases soar

Last Updated: 1:00am GMT 11/03/2008

'Give teenagers jab for whooping cough'

Whooping cough cases soar Doctors said this suggested that teenagers as well as babies should be vaccinated against whooping cough, as in , as in France, Germany and the US

Cases of whooping cough has doubled in last year

In 2003, there were just 386 cases in England but provisional figures suggest there were as many as 1,071 in 2007.

During this period, uptake of the jab remained steady over the last few years - around 93% or 94% coverage between 2003 and 2007.

A vaccine is given to babies. It forms part of the DTaP/IPV/ Hib jab, which protects against diphtheria, tetanus, pertussis, polio and haemophilus influenzae type b

Recent research from the University of Oxford said that while immunisation is effective, doctors needed to be aware that protection did not last indefinitely.

Whooping cough cases fluctuate on about a four year cycle, so there will always be highs and lows that are comparable with fluctuations in other countries

Department of Health

Whooping CoughWhat is whooping cough?

Whooping cough (pertussis) is still a very serious disease when it occurs in children under the age of one year old. But thanks to an effective vaccine and prevention against infection, it is now quite rare.

Whooping cough is a very serious disease when it occurs in children aged under one year. Before the vaccination against whooping cough was introduced, three out of four children caught the disease and some died every year. Today only a few get whooping cough.

What causes whooping cough?

Whooping cough is caused by a bacteria (Bordetella pertussis) and is one of the most contagious bacterial infections.

If one child in a group of siblings gets it, the other children are extremely likely to become infected if they have not already had the disease or been vaccinated.

This also includes babies. Although infants who are breastfed are usually protected against most common childhood infections, they receive no protection against whooping cough. This is why early vaccination is recommended.

Pathophysiology

Bordetella pertussis is an aerobic, nonmotile, gram-negative coccobacillus that attaches to and multiplies on the respiratory epithelium, starting in the nasopharynx and ending primarily in the bronchi and bronchioles. Transmission is only human to human by means of exposure to aerosol droplets. The disease is highly contagious. Approximately 80-90% of susceptible individuals who are exposed develop the disease.

Pathophysiology cont’dA mucopurulous or sanguineous exudate

forms in the respiratory tract. This exudate compromises the small airways (especially those of infants) and predisposes the affected individual to atelectasis, cough, cyanosis, and pneumonia. The lung parenchyma and bloodstream are not invaded; therefore, blood culture results are negative.

AgePertussis occurs predominantly in those aged

3 months to 5 years, with more than 70% of cases reported in children younger than 5 years.

Because of the lack of maternal immunity transfer, 10-15 % of all cases occur in infants younger than 6 months, yet more than 90% of all deaths occur in this same age group

History

Pertussis typically consists of 3 stages: incubation, catarrhal, paroxysmal.

INCUBATION PERIODThe asymptomatic incubation period lasts 7-

10 days.

CATARRHAL STGEThe catarrhal stage follows and lasts about 2-

7 days. Findings include the following:Minimal or no fever Rhinorrhea Anorexia Mild but increasing cough

Paroxysmal stageThe paroxysmal stage follows, lasting about

1-8 weeks.It is characterized by paroxysms of coughing,

which are provoked by feeding (in infants) and exertion.

These paroxysms are less spontaneous than those observed in typical respiratory infections.

The inspiratory gasp or whoop eventually develops, especially in those aged 6 months to 5 years.

Infants younger than 6 months often have vomiting in association with the cough, which leads to dehydration.Hypoxia tends to be more severe than what the

child's clinical appearance suggests. A substantial number of patients present with

cyanosis and apnoeic spells.

Physical

The classic inspiratory gasp or whoop primarily develops in those aged 6 months to 5 years. It is usually absent in those younger than 6 months and in most older vaccinated children and adults;.

Hypoxia should be considered and assessed.Dehydration is common on presentation.Mild fever is common. Fever with a

temperature of over 39°C is rare.

Causes

The main causative organism is B pertussis.Bordetella parapertussis and Bordetella

bronchiseptica are less common than B pertussis and produce a clinical illness that is similar but milder to pertussis due to B pertussis.

Risk factors include the following:Nonvaccination in children Contact with an infected person Epidemic exposure Pregnancy

VaccinationThe vaccination takes place at the age of two,

three and four months as part of the 'five-valent' diphtheria, tetanus, pertussis, Hib, polio vaccination (Pediacel). After the first two vaccinations protection is almost 100 per cent.

However protection wear off after about 10 years

Lab StudiesBlood work

Lymphocytosis is often profound (>70% of the total WBC count), especially in children.

In adults, especially those that had been vaccinated, lymphocytosis is rare.

CulturesA definitive culture diagnosis is not always possible.Results of blood culture are uniformly negative

because B pertussis grows solely in the respiratory epithelium.

An immediately plated, deep, culture of a nasopharyngeal swab sample grown in Regan-Lowe charcoal agar or fresh Bordet-Gengou is considered the criterion standard for those who present within the first 3 weeks of their cough. The results are positive in <50% (perhaps 15-40%) of cases, and results become available too late (about 1 week) to be clinically useful.

LabDirect fluorescent antibody (DFA) studies

DFA studies are performed by using a nasopharyngeal sample. Although the results can be available within minutes, its use is

not recommended because of both low sensitivity and low specificity. Specimens should be obtained within the first 3 weeks of the disease (ie, in incubation, catarrhal, or early paroxysmal stages) or the sensitivity and specificity decrease.

Polymerase chain reaction (PCR) testing to detect DNA PCR testing may reveal <10 organisms per swab sample. Its sensitivity may be greater than that of culturing. False-positive results have been a problem, with some reports of

more than 50%. Although this or a positive culture is the case definition for reporting pertussis to the WHO, some are now recommending ELISA confirmation before declaring an epidemic.   

Enzyme-linked immunosorbent assay (ELISA) is also useful. Many now consider serologic testing with ELISA to be the criterion standard.

Imaging StudiesChest radiography may show focal atelectasis

and/or peribronchial shadowing

Emergency Department CareGeneral supportive measures (eg, oxygenation,

breathing treatments, mechanical ventilation) should be administered as needed.

Infants should be carefully observed for apnoea, cyanosis, or hypoxia.

Patients should be isolated from susceptible individuals (especially infants) for 4 weeks, especially until 5-7 days of antibiotic therapy is completed. When patients present with paroxysmal cough, the clinical course is not shortened, but transmission is considerably decreased after 5 days of therapy.

Factors that should prompt a consideration of admitting the patient are the following:Age younger than 1 year Pneumonia Apneic or cyanotic spells or hypoxia Moderate-to-severe dehydration

The effectiveness of prophylaxis for exposed susceptible persons has not been determined; however, it is recommended for household and close contacts of the patient. Regimens include the following:Erythromycin 50 mg/kg/d divided 4 times a day (qid) for

14 days Alternative: Clarithromycin 7.5 mg/kg 2 times a day (bid)

for 14 days (The effectiveness of clarithromycin has not been proven but is inferred.)

Summary

The disease begins with a cold and a mild cough. After this, the typical coughing bouts set in. The coughing continues until no air is left in the lungs. After this comes a deep intake of breath that produces a heaving, 'whooping' sound when the air passes the larynx (windpipe) that gives rise to the name of the disease.

The patient will eventually cough up some phlegm and these attacks may well be followed by vomiting. The child's temperature is likely to remain normal.

A bout of whooping cough can be very distressing for both the child and the parents who feel unable to help.

Coughing attacks may occur up to 40 times a day and the disease can last for up to eight weeks