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Case of a Coughing Kid

Case of a Coughing Kid. Anna Chollet, MD/MPH March 6, 2013. 19 mo F presents w/cough. Intermittent forceful coughing attacks for 2+ weeks, "like the child is going to die" Especially at night or in car seat Coughs up "thick saliva" Sometimes vomits only when coughing. . More history.

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Case of a Coughing Kid

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  1. Case of a Coughing Kid Anna Chollet, MD/MPH March 6, 2013

  2. 19 mo F presents w/cough Intermittent forceful coughing attacks for 2+ weeks, "like the child is going to die" Especially at night or in car seat Coughs up "thick saliva" Sometimes vomits only when coughing.

  3. More history Low grade fevers One episode of diarrhea Decreased appetite Lives with mom and another family including 4 other children; no known sick contacts

  4. Physical Exam HR 145, Temp 98.5, Oxygen sat % 92 HEENT: "Congested nares"; otherwise wnl CV: regular rhythm, no murmurs PULM: Clear to ausc bilaterally AB: soft, NT, ND, normal bowel sounds EXT: no cyanosis NEURO: interactive, playful, occas cough

  5. Next steps? What else do you want to know? What is on your differential? What tests would you order?

  6. Lab Bordatella pertussis culture: POSITIVE!

  7. B. pertussis or whooping cough Tos Ferina o Tos Convulsiva 3 Stages: 1. Catarrhal: 7-10 days. Coryza, low fever, mild cough 2. Paroxysmal: 1-6 weeks, up to 10 weeks. Paroxysms of coughs, thick mucus expulsion, inspiratory "whoop", cyanosis, vomiting 3. Convalescent: 7-21 days. Gradual recovery, decreasing paroxysms, may recur

  8. Characteristics Paroxysmal cough Inspiratory "whoop" Prolonged cough (2+ weeks)

  9. Pathogenesis Infection by respiratory droplets Bacteria target cilia of respiratory mucosa Bacteria produce toxins which immobilize cilia, damage respiratory epithelium, induce mucus release, inflammation of resp tract Incubation period: usually 7-10 days Most contagious during catarrhal period (1-2 weeks) and first 2 weeks of paroxysmal phase

  10. Epidemiology Worldwide annual incidence in children < 1 yo is 10 million 400,000 deaths per year worldwide Incidence has increased since 1980s in US: - more sensitive tests - increased awareness - improve reporting - whole cell > acellular vaccine

  11. Epidemiology Most affected: Infants too young to be fully immunized, less than 6 months old Hospitalized infants: Apnea 50%, PNA 20%, 1% SZ, 1% death ~50% reported cases in adolescents and adults Usually contracted from family member, especially parents!

  12. Clinical Case Definition If outbreak, cough >= 2 weeks If endemic or sporadic case, cough >=2 wks plus 1+ of the following: - paroxysms of cough - inspiratory "whoop" - post-tussive vomiting - no other apparent cause

  13. Diagnosis Acute cough with positive culture Positive PCR with clinical case definition Clinical case definition and known exposure to patient with positive culture or PCR

  14. Testing Gold std: nasopharyngeal swab culture BUT low sensitivity (30-60%-->1-3% by 3 weeks) PCR: nasopharyngeal sample. More sensitive, rapid results BUT no inter-lab std, more false positives WBC < 9,400 to rule out

  15. Testing continued Some evidence that PCR + serology is most sensitive for ruling out in exposed pts (level 2) CDC does not accept serology for diagnosis

  16. Complications Pneumonia, pneumothorax, pulmonary hypertension, apnea, respiratory failure, syncope Seizure, encephalopathy, cerebral hypoxia FTT from vomiting, incontinence Inguinal hernia, rectal prolapse, rib fx

  17. But she was vaccinated! Vaccine does not eliminate risk for infection Increased cases in 2012 nationwide Waning immunity? Drift in bacterial strains?

  18. When and why antibiotics? Start if pt >1 yo within 3 wks of cough onset if pt <1 yo within 6 wks of cough onset Reduce transmission to others Unlikely to improve dz course Prophylaxis in exposed persons

  19. Post-exposure prophylaxis Same dosage as for treatment Within 3 weeks of exposure of close contact: - close proximity to symptomatic pt >1 hr - direct contact with secretions of symp pt - face to face exposure w/in 3 ft of symp pt High risk pts: < 1 yo, 3rd trim, immunocompromised, underlying lung disease

  20. Vaccines: safest prevention DTaP: 2, 4, 6 mos, then 15-18 mos, then 4-6 yrs Close contact < 7 yo --> complete series Close contact <7 yo: if 3rd dose >6 mo prior to exposure --> give 4th dose Tdap for 10-64 yo post-exposure not eval'd Infection 6x more likely in unvaccinated At least 2 doses needed for protection. 5-6 yrs of protection

  21. Treatment Azithromycin < 6 mo 10 mg/kg/day x 5 days >= 6 mo 10 mg/kg/day on day 1 then 5 mg/kg/day for day 2-5 Adult (or adult size?) 500 mg day 1, then 250 mg day 2-5 TMP-SMX in pts >2 months old and macrolide ineffective/not tolerated

  22. Treatment Setting Home care if uncomplicated dz No school/work for 5 days after starting abx If no Rx, no school until 21 days of cough No exclusions for asymptomatic contacts Hospitalize if apnea, hypoxia, pneumonia, resp distress, need for supp O2, extreme leukocytosis, poor feeding Droplet precautions until 5 days of abx

  23. Take Home Stay vigilant for pertussis in cough > 2 wks! Vaccinate! Treat contacts, if possible Azithro easier to use than erythro Advise parents on expected time course

  24. References http://www.cdc.gov/pertussis/clinical/features.html Brown, M. Pertussis outbreaks on the decline, but immunization gaps still exist. AAFP News Now 1/31/2013 www.aafp.org/online/en/home/publications/news/news-now/health-of-the-public/20130131pertussisdown.html Via DynaMed "Pertussis": Wood, N, McIntyre P. Pertussis: review of epidemiology, diagnosis, management and prevention. Paediatric Respiratory Review. 2008 Sep;9(3): 201-11. Cornia PB, Hersh AL, Lipsky BA, Newman TB, Gonzalez R. Does this coughing adolescent or adult parent have pertussis? JAMA. 2010 Aug 25;304(8): 890-6 Heininger U. Update on pertussis in children. Expert Rev Anti Infect Ther. 2010 Feb; 8(2): 163-173 MMWR Recomm Rep 2005 Dec 9;54 (RR-14):1 full-text Wkly Epidemiol Rec 2010 Oct 1;85(40): 385 JAMA 2000 Dec 27;284(24): 3145

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