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Good Morning!
Friday, August 3rd 2012
Semantic Qualifiers
Symptoms
Acute /subacute
Chronic
Localized
Diffuse
Single
Multiple
Static
Progressive
Constant
Intermittent
Single Episode
Problem Characteristics
Ill-appearing/
Toxic
Well-appearing/
Non-toxic
Recurrent
Localized
problem
Systemic
problem
Abrupt
Gradual
Acquired
Congenital
Severe
Mild
New problem
Painful
Nonpainful
Recurrence of
old problem
Bilious
Nonbilious
Sharp/Stabbing
Dull/Vague
Illness Script
 Predisposing Conditions
 Age, gender, preceding events (trauma, viral illness, etc),
medication use, past medical history (diagnoses, surgeries,
etc)
 Pathophysiological Insult
 What is physically happening in the body, organisms involved,
etc.
 Clinical Manifestations
 Signs and symptoms
 Labs and imaging
Predisposing Conditions: Pertussis
 Highest incidence
 Infants <6mos (not completely immunized)
 Adolescents (due to waning immunity)
• Important infectious source for infants/children
 Risk factors
 Childcare, school outbreaks
 Sick caregiver
Pathophysiology: Pertussis
 Organism: Bordetella pertussis
 Gram-negative pleomorphic bacillus
 Bordetella parapertussis – milder disease
 Transmitted via coughing (aerosolized droplets)
 Infect ciliated epithelium of respiratory tract
 Toxins cause local and systemic effects
 Plugs of necrotic bronchial epithelial tissues and
thick mucus in airways
 VERY contagious during earliest (catarrhal) stage
Clinical Manifestations: Pertussis
 Classic pertussis syndrome (ages 1-10yrs)**
 3 stages
 Catarrhal – nonspecific signs; lasts 1-2 weeks
• Nasal congestion, rhinorrhea, sneezing, tearing, low-grade fever
 Paroxysmal – most distinctive stage; lasts 2-4 weeks
• Paroxysms of coughing during expiration
• Forceful inhalation “whoop”
• http://www.pkids.org/diseases/pertussis.html
• Post-tussive emesis
 Convalescent – resolution of symptoms; lasts 1-2 weeks
• Coughing becomes less severe; whoops disappear
• Residual cough may last for months
Clinical Manifestations: Pertussis
 Infants: not classic**
 Apnea (can hypoxia leading to CNS damage)
 No classic “whoop”
 Secondary bacterial pneumonia common
 Adolescents/adults: not classic**
 Prolonged bronchitis-like illness
 Persistent, nonproductive cough
 Begins as nonspecific URI
 Generally do not have “whoop”, but will have paroxysms
of cough
 Cough lasts weeks-months
Diagnosis**
 Definitive diagnosis based on culture of B.
pertussis from nasopharyngeal specimen
 VERY difficult to isolate
 DFA of nasopharyngeal secretions
 Technically difficult; low sensitivity (~60%)
 PCR is the preferred method
 More sensitive and specific
 CBC: marked leukocytosis and lymphocytosis
Treatment**
 Age < 6 months: strongly consider admit
 Close monitoring (cyanosis, apnea), frequent suctioning,
O2, IVFs, nutrition
 Antibiotics
 1st line: macrolide
 2nd line: TMP-SMX
 Early treatment (catarrhal stage) eradicates
nasopharygeal carriage, shortens duration of illness
 However, treatment during the paroxysmal stage does
NOT alter the clinical course
• Does reduce the spread of secondary cases
 Can return to school after treatment x 5 days
Treatment
Prophylaxis**
 ALL close contacts should receive prophylaxis
(including child care/school contacts)
 Antibiotics
• Same agents, dose, duration as for treatment of pertussis
• Best if within 21 days of onset of cough in index case
 Immunization
• Close contacts who are unimmunized or underimmunized should
also have pertussis vaccine initiated or continued immediately
• DTaP: for children <7 years old
• Tdap: for children ages >7 years old
Routine Pertussis Vaccine
Recommendations
 DTaP: 5 doses
 2months, 4months, 6months, 15-18months, 4-6years
 Tdap: 1 dose
 11-12years
 Immunization with Tdap (if not received previously) is
recommended for adults who will have close contact with
an infant aged <12 months (at least 2 weeks prior to
contact with the infant)
 Contraindications for pertussis vaccine**:
 Allergic reaction, unstable or active CNS disease, encephalopathy
within 7 days of receiving prior pertussis vaccine
Waning Immunization**
 Neither infection with active disease or vaccination
provides complete or lifelong immunity
 Protection begins to wane 3-5 years after vaccination
 No discernable immunity after 12 years
THANK YOU!!
Noon conference: Residents as Teachers
(Dr. English)
Students off!!