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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!!