Pediatrics, Pertussis

Author: Joseph J Bocka, MD, Director of Shelby Emergency Department, Attending Emergency Physician
at Mansfield Hospital, Med Central Health System (Mansfield and Shelby, Ohio); Emergency Medical Service
Medical Director for several services
Contributor Information and Disclosures
Updated: May 26, 2009

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Introduction

Background
In the prevaccination era, pertussis (ie, whooping cough) was a leading cause of infant death.
The number of cases reported had decreased by more than 99% from the 1930s to the 1980s.
However, because of many local outbreaks, the number cases reported in the United States
increased by more than 2300% between 1976 and 2005, when the recent peak of 25,616 cases
were reported.1 The disease is still a significant cause of morbidity and mortality in infants
younger than 2 years. Pertussis should be included in the differential diagnosis of protracted
cough with cyanosis or vomiting, persistent rhinorrhea, and marked lymphocytosis.

Pathophysiology
Bordetella pertussis is an aerobic, nonmotile, gram-negative coccobacillus that attaches to and
multiplies on the respiratory epithelium, starting in the nasopharynx and ending primarily in the
bronchi and bronchioles. Transmission is only human to human by means of exposure to
aerosol droplets. The disease is highly contagious. Approximately 80-90% of susceptible
individuals who are exposed develop the disease. Most cases occur in the late summer and
early fall.

A mucopurulosanguineous exudate forms in the respiratory tract. This exudate compromises

the small airways (especially those of infants) and predisposes the affected individual to
atelectasis, cough, cyanosis, and pneumonia. The lung parenchyma and bloodstream are not
invaded; therefore, blood culture results are negative.

Frequency
United States

The rate of pertussis peaked in the 1930s, with 265,269 cases and 7518 deaths reported in the
United States. This rate decreased to a low in 1976, when 1010 cases and 4 deaths occurred.
The rate recently peaked to 25,616 cases (8.7 cases per 100,000 people per year) reported to
the Centers for Disease Control and Prevention (CDC) in 2005 and 15,632 (5.2 per 100,000)
reported in 2006. The CDC estimates that 5-10% of all cases of pertussis are recognized and
reported. Pertussis remains the most commonly reported vaccine-preventable disease in the
United States in children younger than 5 years.

In reported studies, 12-32% of adults with prolonged (1-4 wk) cough have pertussis.

International

In England, the percentage of people vaccinated over the last 4 decades decreased to less than
30%. This decline has resulted in thousands of cases reported recently, a rate that approaches
the incidence in the prevaccination era. Similar epidemic outbreaks have recently occurred in
Sweden, Canada, and Germany. Nearly 300,000 deaths from pertussis in Africa are thought to
have occurred over the last decade.

Mortality/Morbidity
The mortality rate had been greater than 50%. Now, the mortality rate for hospitalized patients
in the United States and in Europe is about 1 per 500 cases (<0.2% of those reported). The
overall infant mortality rate is 2.4 per 1 million live births. The CDC reported 39 deaths from
pertussis in 2005; 32 (82%) occurred in infants younger than 3 months. The World Health
Organization (WHO) estimates that 294,000 children died from pertussis worldwide in 2002.

• About 90-95% of patients die from secondary pneumonia, dehydration, hypoxia,

encephalopathy, or cerebral hemorrhage. Cerebral hemorrhage occurs secondary to
paroxysmal coughing, which elevates the intracranial pressure (ICP).
• Today, about 10-25% of children younger than 4 years and 2-4% of all persons with
pertussis secondarily develop bacterial pneumonia. Approximately 1-2% of infants and
0.3-0.6% of adults develop seizures, which are believed to be a result of hypoxia or
cerebral hemorrhage from the prolonged coughing spells. About 0.1% develop
encephalopathy.
• In the prevaccination era, pertussis caused more than 270,000 cases and nearly 10,000
deaths annually. This rate reached a low of 4 reported deaths in the United States in
1982 and has recently risen to an average of about 25 deaths annually, with 39 being
reported in 2005.
Sex
Pertussis is more common in girls than in boys.

Age

• Pertussis occurs predominantly in those aged 3 months to 5 years, with more than 70%
of cases reported in children younger than 5 years.
• Because of the lack of maternal immunity transfer, 10-15 % of all cases occur in infants
younger than 6 months, yet more than 90% of all deaths occur in this same age group.
However, the growing majority of cases are now in those aged 10 years and older, which
has led to increased booster recommendations.
• The natural disease does not provide lifelong immunity as earlier thought. Three
injections of the cellular or acellular vaccine provide up to 12 years of protection. These
vaccinations help account for the more than 10-fold increase reported in those older than
18 years.

Clinical

History

• Pertussis typically consists of 3 stages: incubation, catarrhal, and paroxysmal.

• The asymptomatic incubation period lasts 7-10 days.
• The catarrhal stage follows and lasts about 2-7 days. Findings include the following:
o Minimal or no fever
o Rhinorrhea
o Anorexia
o Mild but increasing cough
• The paroxysmal stage follows, lasting about 1-8 weeks.
o It is characterized by paroxysms of coughing, which are provoked by feeding (in
infants) and exertion.
o These paroxysms are less spontaneous than those observed in typical
respiratory infections.
o The inspiratory gasp or whoop eventually develops, especially in those aged 6
months to 5 years.
• Infants younger than 6 months often have vomiting in association with the cough, which
leads to dehydration.
o Hypoxia tends to be more severe than what the child's clinical appearance
suggests.
o A substantial number of patients present with cyanosis and apneic spells.
• Vaccinated adults usually develop only prolonged bronchitis without a whoop, whereas
unvaccinated adults are most likely to have whooping and posttussive emesis.
 • About 12-32% of adults with persistent cough (>2 wk) have pertussis. On average, they
wait a median of 3 weeks before seeking treatment.

Physical

• The classic inspiratory gasp or whoop primarily develops in those aged 6 months to 5
years. It is usually absent in those younger than 6 months and in most older vaccinated
children and adults; however, it can often be observed in unvaccinated adults, as can
posttussive emesis.
• Hypoxia should be considered and assessed.
• Dehydration is common on presentation.
• Mild fever is common. Fever with a temperature of over 39°C is rare.

Causes

• The main causative organism is B pertussis.

• Bordetella parapertussis and Bordetella bronchiseptica are less common than B
pertussis and produce a clinical illness that is similar but milder to pertussis due to B
pertussis.
• Risk factors include the following:
o Nonvaccination in children
o Contact with an infected person
o Epidemic exposure
o Pregnancy

http://emedicine.medscape.com/article/803186-overview