Download 84 yo woman with a cough: epidemiologic implications

84 yo woman with a cough
Mary H. Pak, M.D., FACP
Primary Care Conference
February 22, 2006
Disclosure
Received honorarium for being on an
advisory panel for Pfizer related to
linezolid.
Case presentation
• EG is an 84 yo woman who presented to the
ER with a cough of 1-2 weeks in duration.
– She notes some shortness of breath, mostly
related to the coughing fits as well as intermittent
chest pains.
– There is no sputum production.
– She has had difficulty sleeping because of the
coughing.
– She has some nausea related to the cough but no
emesis.
Case presentation (con’t)
• PMH:
Metastatic renal cell CA (treated in
eastern Europe, s/p
nephrectomy 6 years ago)
Hypertension
Arthritis
Depression
Case presentation (con’t)
Medications:
captopril 50 mg po b.i.d.
Ambien prn
Robitussin (OTC)
Tylenol prn
Allergies: Morphine  nausea
SH/FH: widowed, lives with daughter in
Madison. Denies any tobacco or alcohol
use. FH heart disease, no other cancers. No
information about her immunization history.
Case presentation (con’t)
ROS:
No fevers, chills or sore throat
No sputum production or
hemoptysis
No known sick contacts
Irritated and itchy eyes occasionally
Diffuse arthralgias
Case presentation (con’t)
Physical Examination
– T 98.9, BP 145/64, pulse 70, resp 16, 95% RA
– Lungs were clear to auscultation B/L
– Heart was regular in rhythm with no
appreciable gallops, murmurs or rubs
– Extremities were noted to have trace ankle
edema with negative Homan’s sign
Case presentation (con’t)
Laboratory data:
• WBC 8.1 (normal diff), H/H 11.5/33, plt 285
• Normal electrolytes, creatinine 1.7, BUN 40
• BNP 175
• Troponin 0.1
• D-dimer 0.6
Case presentation (con’t)
• Differential diagnosis:
 viral URI (including RSV, adenovirus) or URI
symptoms related to Influenza type virus
 atypical respiratory infections including
Mycoplasma pneumoniae, Chlamydia
pnueumoniae, Bordetella pertussis, Bordetella
parapertussis
 Cough secondary to post nasal drip
 GERD
Case presentation (con’t)
• We sent off a nasopharyngeal swab for
Bordetella pertussis DNA PCR and culture
• Placed the patient in respiratory droplet
isolation
• Started azithromycin 500 mg
Objectives
• Case presentation
• Differential diagnosis of prolonged cough
• Discussion regarding epidemiology,
diagnosis and treatment of pertussis
• Role of adult vaccination
Bordetella pertussis: epidemiology
• 25,827 cases reported in the U.S in 2004
 60% cases in adolescents (11-18) and adults (>20)
• Transmitted from person-to-person through
aerosolized respiratory droplets from cough or
sneeze or direct contact with secretions from
infected persons.
• Incubation period 5 – 21 d (typical 7 – 10d)
• Endemic in U.S., epidemic every 3 - 4 years.
Tiwari T, MMWR 2005
MMWR 54 (50), 1284
MMWR 54 (50), 1285
Bordetella pertussis: economics
• Pertussis in adults has been shown to
generate medical and nonmedical costs of
$773 per case-patient.
• Often leads to 10 days of missed work.
Lee GM, Clin Inf Dis 2004
Bordetella pertussis
• Uniquely human pathogen
• Only disease for which universal childhood
vaccination is recommended that has an
increasing trend in reported cases in U.S.
 In early vaccine years (1920 – 40), average
annual rate 150 per 100,000 population
 After universal vaccination during 1940’s,
declined to 1 case per 100,000.
 In 2004, 8.4 cases per 100,000
Robbins JB, Clin Inf Dis 1999
Tiwari T, MMWR 2005
Bordetella pertussis: clinical
manifestations
• Catarrhal period (1 – 2 weeks)
 Coryza, mild fever, non productive cough
 Infants can have apnea and respiratory distress
• Paroxysmal period (2 – 6 weeks)
 Paroxysmal cough, inspiratory “whoop”,
posttussive vomiting
• Convalescent period (> 2 weeks)
Tiwari T, MMWR 2005
Bordetella pertussis: clinical
manifestations
• Potential complications:
– Weight loss (due to coughing)
– Sleep disturbance
– Effects generated by increased pressure due to
severe coughing including pneumothorax,
epistaxis, subconjunctival hemorrhage, subdural
hematoma, rib fracture, urinary incontinence.
– Secondary bacterial pneumonia including
aspiration pneumonia related to posttussive
vomiting
Dworkin MS, Ann Intern Med 2005
Tiwari T, MMWR 2005
Bordetella pertussis: testing
• Culture of the nasopharyngeal mucus is the
“gold standard”
 Prefer aspiration samples via hand-trap
 If swabs are to be used, Dacron is
recommended since alginate may inhibit PCRbased assays and cotton may be toxic to the
bacteria.
• Send for B. pertussis PCR and culture.
Dworkin MS, Ann Intern Med 2005
Bordetella pertussis: diagnostic
barriers
• Reluctance to cause patient discomfort
• Need for special transport medium (BordetGengou medium)
• Tendency for the organism to die before culture
confirmation
• Low yield of PCR and culture in the setting of
partial immunity
• Chronicity of cough delays diagnosis to a time
when diagnostic yield is poorest.
• Lack of reliable serologic markers
Dworkin MS, Ann Intern Med 2005
Testing for pertussis is not sufficiently
sensitive for treatment decision to be guided
by test results alone.
Bordetella pertussis: treatment
Tiwari T, MMWR 2005
Bordetella pertussis: vaccination
• In May, 2005, Boostrix (GlaxoSmithKline)
was licensed for vaccination in persons
between the ages of 10 – 18.
• In June, 2005, Adacel (Sanofi-Aventis) was
licensed for use in person between 11 – 64
years.
• Both vaccines are Tdap vaccines which
contains tetanus, diphtheria and acellular
pertussis.
MMWR 2005; 54 (50)
Bordetella pertussis: vaccination
• On June 30, 2005, the Advisory Committee
on Immunization Practices (ACIP)
recommended a single dose of Tdap for all
persons aged 11 – 18 years.
• In October, 2005, ACIP recommended a
single dose of Tdap for adults aged 19 –64.
• No adoption into immunization guidelines
as yet.
Conclusion
• Pertussis is not solely a childhood disease. Pertussis
is a “community-acquired disease of all ages”
• Reported cases of pertussis has been rising
significantly particularly in the adolescents and
adults.
• Diagnostic testing is not always reliable. Presumptive
treatment with a macrolide is recommended.
• Additional vaccinations in adulthood might help to
decrease the reservoir of pertussis.
References
1)
2)
3)
4)
5)
6)
7)
Dworkin MS. Adults are Whooping, but Are Internists Listening?
Ann Intern Med 2005; 142: 832-835.
Tiwari T, Murphy TV, Moran J. Recommended Antimicrobial Agents
for the Treatment and Postexposure Prophylaxis of Pertussis: 2005
CDC Guidelines. MMWR 2005; 54 (RR-14): 1- 15.
Pertussis – United States, 2001 – 2003. MMWR 2005; 54 (50):
1283-1286.
Cherry JD. Epidemiological, Clinical and Laboratory Aspects of
Pertussis in Adults. Clin Inf Dis 1999; 28 (Suppl 2): S112-S117.
Keitel WA. Cellular and Acellular Pertussis Vaccines in Adults. Clin
Inf Dis 1999; 28 (Suppl 2): S118-S123.
Gardner P. Indications for Acellular Pertussis Vaccines in Adults: The
Case for Selective Rather than Universal Recommendations. Clin Inf
Dis 1999; 28 ( Suppl 2): S131-S135.
Orestein WA. Pertussis in Adults: Epidemiology, Signs, Symptoms
and Implications for Vaccination. Clin Inf Dis 1999; 28 (Suppl 2)
S147-S150.
References (con’t)
8)
9)
10)
Ward JI, et al. Efficacy of an Acellular Pertussis Vaccine among
Adolescents and Adults. N Eng J Med 2005; 353: 1555-1563.
Robbins JB. Pertussis in Adults: Introduction. Clin Inf Dis 1999; 28
(Suppl 2): S91-93.
Hewlett EL. A Commentary on the Pathogenesis of Pertussis. Clin
Inf Dis 1999; 28 (Suppl 2): S94-S98.