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NYU Medical Grand Rounds
Clinical Vignette
Christopher Schultz, MD, PGY-2
February 24, 2010
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
A 53-year-old man presents with fever,
cough and malaise for ten days.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The patient was in his usual state of good health until
three weeks prior to presentation, when he was reunited
with his 11-year-old son who had been away at camp.
• The son had returned home with malaise and a nonproductive paroxysmal cough associated with vomiting.
• The boy’s illness persisted for one week and resolved
without treatment.
• The child had no fever throughout his illness and was
reported to have received all routine age-appropriate
childhood vaccinations.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• One week prior to presentation, the patient began to
experience malaise and cough.
• Over the next four days, the patient’s condition did not
improve, and he began experiencing fever, head ache
and chest pain in addition to his original symptoms.
• He presented for further evaluation.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
Past Medical History
• None
• Unknown vaccinations
Family History
• Mother: diabetes mellitus
Social History
Past Surgical History
• None
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
• Born in Bermuda
• Divorced
• Lives with son
• One bedroom apartment
• Lifetime non-smoker
• Social alcohol use
• Denies illicit drug use
Outpatient Medications
None
Allergies: None
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
General: Well-appearing man in no acute distress,
experiencing occasional cough
Vitals: T 100.7, BP 125/85, HR 85, RR 14
O2 saturation: 98% on room air
The remainder of the physical exam was normal.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Initial Studies
• CBC:
• White blood cell count 16,000
• Lymphocytic predominance
• The remainder was within normal limits
• Basic Metabolic Panel: Within normal limits
• Hepatic Panel: Within normal limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Imaging
Chest X-Ray
• Mild bilateral basilar atelectasis
• No consolidation or effusions noted
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Initial Studies
Sputum Gram Stain:
• Large numbers of polymorphonuclear leukocytes
• Some gram-negative coccobacilli.
Sputum culture was collected.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working diagnosis
Bronchitis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• The patient was prescribed ampicillin-clavulanic acid, but
his symptoms persisted.
• Growth from the patient’s sputum culture was consistent
with a normal respiratory biota.
• Two weeks into the patient’s illness, he developed
paroxysmal coughing with occasional vomiting.
• These paroxysms increased over several weeks, and
persisted for over one month.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• During his prolonged clinical course, the patient underwent
additional serologic testing at a follow-up visit.
• IgG and IgA antibody titers to filamentous hemagglutinin
and pertussis toxin were obtained and markedly elevated.
• Two weeks later, the patient’s coughing paroxysms finally
resolved.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
Acute Bordetella pertussis infection
transmitted through a previously immunized
child presenting with atypical disease
Case report modified from: Smith S and RC Tilton. Journal of Clinical Microbiology 1996; 34: 429-30.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS