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Morning Report 1/14/19

Ted Tanner MD, MPH, MA


Ted.Tanner@hsc.utah.edu
7-week-old male
• Presents to ED with concern for “breathing
pauses” and cyanosis in setting of a cough for
1.5 weeks
• Patient was having breathing pauses of 20-30
seconds this morning along with post-tusive
emesis
• Parents had to stimulate him several times
during these episodes
• Apneic/hypoxic episode in triage
HPI continued
• No recorded fevers
• Waking up to breastfeed every 2-3 hours, but
coughing so much that mom does not think he
is getting much milk
• 4 wet diapers in last 24h
• Urine appears more concentrated
• Older sister sick for 2 weeks, mom with
lingering cough
• Born 39wks, uncomplicated pregnancy and
delivery, no NICU, discharged home at 48h
with mom
• Exclusively breastfed
• Unimmunized, waiting to get first Hep B
• Siblings and parents healthy, all UTD on
immunizations
• Lives with family, no smoke exposure, no
daycare, 3 yo sibling does not attend daycare
• Ranitidine started 1 week ago by PCP, NKDA
On 1LPM NC
Apnea and Cough
• Differential
Differential
Infectious Other
• Mycoplasma • Foreign body aspiration
• Chlamydia • Asthma/ RAD
• TB • Allergic sinusitis
• B. pertussis • GER/GERD
• Aspiration pneumonia
• Viral pathogens:
• CF, primary ciliary dyskinesia
– RSV
– Adeno
• BRUE
– Parainfluenza • Tracheomalcia and congenital
anomalies of upper airway
– Flu A/B
• Cysts and tumors
– Rhino
– HMPV
• Anemia
• Other metabolic disorders
• Seizures
Bordetella pertussis
• Gram- coccobacillus
• Can only survive few
hours in respiratory
secretions outside
human host
• Co-infection with other
pathogens (RSV, adeno,
etc.) may occur
Transmission
• The disease is highly contagious. 80% of non-
immune will get infected when exposed
• Incubation period 1-3 weeks, typically 7-10 days
• Spread via respiratory droplets
• One study found 1/3 of exposed individuals
within households develop pertussis
– ½ of asymptomatic individuals had lab evidence
– Remainder had mild respiratory illness
– Asymptomatic infection is common and one can
transmit the infection to others!
• Most children catch the disease from adults
Epidemiology
Epidemiology
Pathogenesis
“The Cough of 100 Days”
Atypical presentations
• Infants < 4 months:
– Short or absent catarrhal phase where they may
appear relatively well
– A paroxysmal stage with gagging, gasping, apnea,
bradycardia, cyanosis
– Complications include apnea, seizures, respiratory
failure, pneumonia, pulmonary HTN, shock, renal
failure, death
Atypical presentations
• Vaccinated children:
– Symptoms less severe, shorter hospital stays, less
apnea
• Older children and adolescents
– Asymptomatic or mild cough/URI-type illness
– Wheezing
Complications
• Apnea often in those less than 6 months
• Rib fractures and hernias
• Pneumonia
• Seizures and encephalopathy
• Death
– Case fatality rate is 1% in infants <6 months
National Notifiable Diseases Surveillance System (NNDSS)

SEE CDC
Management
• Hospitalization all infants <4 mo
• Isolation
• No proven benefit of bronchodilators,
corticosteroids, antihistamines, and
antitussive agents
• Antibiotics
Work-up findings
• Absolute lymphocyte count often >/= 10,000
• Degree of leukocytosis is associated with
disease severity
– 60,000= pneumonia or pulm HTN
• CXR may be normal or show nonspecific
perihilar infiltrates
• PCR or culture
Antimicrobial therapy
• Top choice is azithromycin
• Caution regarding idiopathic hypertrophic
pyloric stenosis in infants
• Alternatives: the other macrolides or bactrim
Postexposure Prophylaxis
• All household and close contacts of index case
• High risk individuals (pregnant,
immunodeficient, persons who have contact
with infants, persons with chronic medical
condition)
• Effective when initiated within 21 days of the
onset of cough
Immunization
• DTaP • Tdap
– 2/4/6 months – Booster between 11-12
– 15-18 months yrs
– 4-6 years – Pregnant women in 3rd
trimester of every
pregnancy
– Adults 1 dose every 10
years
Efficacy and Effectiveness
• The efficacy is approximately 85% in
preventing typical pertussis (95% for diptheria
and tetanus)
• Effectiveness demonstrated by marked decline
in cases since vaccine introduction in 1940s
• In one large study 5 doses of Dtap was
associated with decreased risk of pertussis
and estimated vaccine effectiveness of 89%
• Protection after an infection is not life-long
Vaccine Risks
• Pain, redness, swelling (more common after 4th)
• Mild fever
• Fussiness, fatigue, lack of appetite
• Nausea, vomiting, diarrhea
• Extensive swelling of limb (3 in 100)
• Severe reactions (1 in 10,000)
– Fever >105
– Febrile seizures
– Inconsolable crying
– Hypotonic-hyporesponsive syndrome = child is listless
and lethargic with poor muscle tone for several hours
Contraindications and Precautions
• Do not give in patients who have had a severe
allergic reaction or to a person with a severe
allergy to any of the vaccine components
• Use precaution in:
– Those who have had a moderate or severe acute
illness with or without fever
– Guillain-Barre within 6 wks after a previous dose
of tetanus toxoid-containing vaccine
– A history of Arthus-type hypersensitivity reaction
Protecting Infants
• “Borrowed” Immunity- from the mom getting
the vaccine between 27-36 wks gestation,
antibodies cross placenta
• “Cocooning”- family members and those close
to the baby getting vaccinated
Children’s Hospital of Philadelphia
Vaccine Education Center
https://www.chop.edu/centers-programs/vaccine-education-center