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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 Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine http://clinicalcorrelations.org UNITED STATES DEPARTMENT OF VETERANS AFFAIRS