Machine Gun Kelly

Case 3 MACHINE GUN KELLY

QUESTIONS TO BE ANSWERED 1. 2. 3. 4. 5. 6.

At this point, what diseases must be entertained? What is a typical picture of a Classic illness of Pertussis? What is/are the differential diagnosis? How is the diagnosis of Pertussis achieved? What are the complications of Pertussis? What is the treatment and preventive measures for Pertussis?

MACHINE GUN KELLY Kelly, 7 mos old whose immunizations were frequently postponed was brought in because of paroxysmal cough of 9 days duration preceded 2 wks earlier by low-grade fever, coryza and dry irritating hacking cough becoming progressively severe and paroxysmal & ending with a high-pitched whoop followed by vomiting.

MACHINE GUN KELLY  Cough

was likened to a machine gun burst of uninterrupted coughing with the chin and chest held forward; the tongue protruding maximally, the eyes bulging and watery and the face turning purple. At the ER, he was visibly exhausted with subconjunctival hemorrhages.  CBC was done.

Q1: At this point, what diseases must be entertained?

MACHINE GUN KELLY 

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Paroxysmal cough is limited to a few conditions. The classic paroxysms, is described as a repetitive series of 5 to 10 forceful coughs during a single expiration followed by a sudden massive inspiratory effort and a characteristic whoop occur as air is forcefully inhaled through a narrow glottis Attacks may be triggered by yawning, sneezing or physical exertion Textbook of Pediatric Infectious Diseases (Feigin)

MACHINE GUN KELLY 

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The conditions that should be highly entertained are: Pertussis syndromes (Bordetella pertussis,B. parapertussis etc),Acute bronchiolitis and Endobronchial TB. Other infectious agents that may be confused with pertussis are M. pneumoniae, C. trachomatis, C. pneumoniae, Adenoviruses and other respiratory viruses

Q2: What is a typical picture of a Classic illness of Pertussis?

Pertussis 

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Classic illness occurs as a primary infection in unimmunized children between 1 and 10 years of age The illness lasts 6 – 8 weeks and has 3 stages: catarrhal (most contagious), paroxysmal (most diagnostic) and convalescent The whoop consists of a high pitched inspiratory noise following prolonged expiration associated with coughing bursts

Pertussis 

In a severe attack, the face becomes flushed, florid and cyanosed. The tongue is often protruded, the eyes watery and sticky mucus is brought out from the mouth

Pertussis  

As a rule, the paroxysms are followed by vomiting of ingested food or thick mucus In the very young (<6 mos.)where pertussis is more severe, cough and catarrhal symptoms are less marked (atypical) and the presentation is frequently of recurrent attacks of apnea and cyanosis. Whoop may be absent

Q3: What is/are the Differential Diagnosis?

Acute Bronchiolitis 

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Most common serious respiratory infection of infancy RSV is the pathogen in 75-80% of cases 90% aged 1 – 9 mos. CXR: hyperinflation of lungs due to small airway obstruction and air trapping

Lung hyperinflation with flattening and depression of diaphragm & increased Bronchial markings

Illustrated Textbook of Pediatrics; Lissauer T , Clayden G.

Acute Bronchiolitis 

Findings on examination: – – – –

Sharp, dry cough Tachypnea Subcostal and intercostal retraction Hyperinflation of the chest • Prominent sternum • Liver displaced downwards

– Fine end inspiratory crackles – High pitched wheezes • Expiratory > inspiratory

– Tachycardia – Cyanosis or pallor

Endobronchial Tuberculosis  Signs

and symptoms include moderately high fever, anorexia, night sweats, loss of weight and paroxysmal cough ending in cyanosis  Diagnosis established by (+) Mantoux test and radiologic findings of hyperaeration, atelectasis and enlarged lymph nodes on lateral view

Endobronchial Tuberculosis 

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Roentgenographic shadows: called CollapseConsolidation”/“Right Middle Lobe Syndrome” Due to enlarged peribronchial lymph nodes impinging & compressing neighboring regional bronchus Segmental lesion resulting in a fan shaped density on x-ray representing atelectasis

Right Middle Lobe Syndrome

Tuberculosis in Infancy & Childhood; PPS Task Force on TB

Pertussis respiratory complications  

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Pneumothorax Mediastinal and subcutaneous emphysema Diaphragmatic rupture

DISCLOSURE: CBC revealed WBC of 40,000 with 90% lymphocytes

Q4: How is a diagnosis of Pertussis achieved?

Diagnosis of Pertussis  Basis:

history and the clinical presentation - apnea in infants, prolonged cough, inspiratory whoop, post-tussive vomiting or cyanosis and lymphocytosis – The history of absent or incomplete immunization & contact with a known case help make the dx – Usually, not suspected until the cough becomes paroxysmal – Laboratory: an absolute and relative lymphocytosis to levels of 20,000 – 50,000 (resemble leukemia)

Diagnosis of Pertussis  Isolation

of B. pertussis is difficult (fastidious organism) but possible with nasopharyngeal swab culture on Bordet-Gengou agar or Regan-Lowe transport media inoculated at bedside during catarrhal stage

Q5: What are the complications of Pertussis?

Complications 

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Bronchopneumonia (from B. pertussis or 20 bacterial infection) – 22% (Red Book) Seizures ( 2%) Encephalopathy (0.5%) Otitis media Subconjunctival hemorrhages, epistaxis, hemoptysis from increased venous Subconjunctival hemorrhage pressure following coughing May precipitate marasmus and kwashiorkor

Q6: What is the treatment and preventive measures for Pertussis?

Treatment of Pertussis 

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Infants <6 months and patients with severe disease require hospitalization for supportive care to manage apnea, hypoxia, feeding difficulties etc. Antimicrobials given during catarrhal stage ameliorate the disease. After cough is established, antimicrobial agents have no discernible effect but recommended to limit the spread of organisms DOC: Erythromycin estolate 40-50 mkd for 14 days, or the newer macrolides (azithromycin, Clarithromycin) Red Book, 2003

Preventive measures  Pertussis

immune globulin is of no

benefit.  All vaccines contain pertussis toxoid  Universal immunization with a total of 5 doses of pertussis vaccine (contained in DPT combination vaccines) is recommended before school entry  In the USA, DTaP is preferred for all doses  Erythromycin prophylaxis of close contacts is recommended

DTP Adverse Reactions Local and febrile reactions (frequency 1 – 4%): redness, edema, induration and tenderness at injection site. Drowsiness, fretfulness, anorexia, vomiting, crying and slight to moderate fever  Allergic reactions 2/100,000 injections  Seizures: within 48 hrs of DTPw  Hypotonic-hyporesponsive episodes  Hyperpyrexia 

Red Book 2003

Contraindications & Precautions to Pertussis immunization 

Contraindications: – Immediate anaphylactic reaction – Encephalopathy within 7 days

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Precautions – Seizure with or without fever within 3 days – Persistent, severe, inconsolable screaming or crying for 3 or more hours within 48 hrs of immunization – Collapse or shock-like state (HHE) within 48 hrs. – Temp >40.50C unexplained by another cause, within 48 hrs of immunization

Key Learning Points  

Pertussis is highly contagious for the unimmunized or partly immunized child Pertussis immunity from natural infection is not absolute and immunization may not prevent infection because immunity acquired wanes with time – Immunization protects against symptomatic disease rather than infection (Vaccines: Children and Practice vol 6 No 1)

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Increasing evidence that pertussis in adolescents and adults occurs more frequently than previously thought (Vaccines; Children and Practice)

Case 3 MACHINE GUN KELLY