Dr.Rithwik Sunil, Dr.Sajith Kesavan, Dr.Greeshma Issac,Dr Benoy Jagadeesh, Dr Shaziya, Dr Sivakami, Dr. Ashwin, Dr C Jayakumar
One month old , recieved only birth, dose vaccine presented with cough since 10 days. Parents then noticed bluish discolouration along with uprolling of eyes and difficulty in breathing during the coughing episode
She was intubated for the same in a near hospital and then shifted to PICU care in AIMS.
At admission child was afebrile .
Chest Xray Right upper lobe pneumonia. Labs showed leucocytosis with elevated inflammatory markers.
ECHO done showed a small PFO only
Respiratory viral panel was sent
Differentials kept in mind at this junction were;
Viral pneumonia
Structural lung malformations
Congenital cyanotic heart disease
Tracheomalacia
Intracranial bleed
Foreign body aspiration
Viral myocarditis
Respiratory Panel revealed Bordetella pertussis. This was later confirmed with a pertussis Real Time PCR
Upon diagnosis, child was started on Inj Azithromycin and other supportives.
Child was continued on ventilator and eventually extubated once xray showed improvement.
Bordetella Pertussis
The clinical spectrum of B. pertussis illness in young infants extends from a trivial illness to severe illness resulting in death. This spectrum is influenced many factors, including the presence and magnitude of transplacentally acquired antibodies to B. pertussis antigens, the sex of the infant, the age and weight of the infant at the time of exposure, the concentration of the bacterial exposure, and whether or not the infant was breastfed.
In classic illness, the infant will look deceptively well; he or she will have coryza, sneezing, and mild cough. Most importantly, there is no fever. This constellation of rather trivial symptoms often leads the physician away from realizing the potential for an upcoming serious illness and from doing further diagnostic study. What would be the paroxysmal stage in older children is characterized lack of fever, gagging, gasping, eye bulging, bradycardia, cyanosis, and vomiting along with total whoop . Most young infants will have leukocytosis with lymphocytosis and very low ESR .During this paroxysmal stage, there will be apneic episodes at the end of a coughing and these apneic episodes may result in seizures. During paroxysms there is respiratory distress, but once the fit is over there will be no distress, and physical examination of the chest will be normal. In young infants, primary B. pertussis pneumonia may occur and this may lead to continued respiratory distress. It is important to note that wheezing is not a manifestation of pertussis unless there is a concomitant or secondary viral infection. Children with severe, potentially fatal illness will develop pulmonary hypertension and pneumonia and will have rapid pulse and respiratory rates. Death is associated with hypotension and organ failure. It is important to note that although apneic episodes are frightening, they do not cause death. However, the hypoxia associated with an apneic episode may be a causative factor in later epilepsy and subsequent intellectual impairment.
Similar to the clinical spectrum, the duration of illness is influenced many factors; the most important factors are whether the mother received tetanus, diphtheria, and pertussis (Tdap) immunization during the pregnancy and whether the infant received diphtheria, tetanus, and acellular pertussis vaccine (DTaP). The majority of data relating to the duration of illness have been reported in hospitalized infants.
Studies done in the whole-cell vaccine era indicated that the source of infection in an infant was usually an adult family member with a cough illness that was not recognized as pertussis . In the more recent acellular pertussis vaccine era, it was noted in one study that the main source of pertussis in an infant was an adolescent family member for whom acellular pertussis vaccine failed .
The greatest risk factor for pertussis in young infants is family size and extended family size . The larger the family and extended family size, the greater the likelihood that there is a person with a cough illness that has not been recognized as pertussis.
Take home message
Tdap (Tetanus,adolescent dose of Diphtheria and acellular pertussis ) to all pregnant women, with each pregnancy, during the second or third trimester (before 36 weeks’ gestation) along with administration of the first Dose of Pertussis containing vaccine to the infant at 6 weeks of age will prevent neonatal pertussis and severe cases of infant pertussis.
Editors note
This year Pertussis /pertussoid cough is very much on the rise among adolescents
As in the case that is reported clinical suspicion can avoid unnecessary investigation
Cough and severe distress during the violent act of coughing is mostly nocturnal
Macrolides along with a short course of steroid could curtail the duration of illness
All unaffected family members may be given three day course of macrolides to prevent the infection occurring intnem
