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Key Features

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Essentials of Diagnosis
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  • Prodromal catarrhal stage (1–3 weeks) characterized by mild cough and coryza, but without fever

  • Persistent staccato, paroxysmal cough ending with a high-pitched inspiratory "whoop"

  • Leukocytosis with absolute lymphocytosis

  • Diagnosis confirmed by PCR or culture of nasopharyngeal secretions

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General Considerations
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  • An acute, highly communicable infection of the respiratory tract caused by Bordetella pertussis characterized by severe bronchitis

  • Children usually acquire the disease from symptomatic family contacts

  • Bordetella parapertussis and Bordetella holmesii cause a similar but milder syndrome.

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Demographics
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  • Cases have increased in the United States since 2000

  • In 2007, about 10,000 cases were reported; increased to more than 16,000 cases in 2009, and 48,277 cases in 2012

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Clinical Findings

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Symptoms and Signs
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  • Onset is insidious, with catarrhal upper respiratory tract symptoms (rhinitis, sneezing, and an irritating cough)

  • Slight fever may be present; temperature > 38.3°C suggests bacterial superinfection or another cause of respiratory tract infection

  • After about 2 weeks, cough becomes paroxysmal, characterized by 10–30 forceful coughs ending with a loud inspiration (the whoop)

  • Vomiting commonly follows a paroxysm

  • Coughing is accompanied by cyanosis, sweating, prostration, and exhaustion

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Differential Diagnosis
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  • Bacterial, tuberculous, chlamydial, and viral pneumonia

  • Cystic fibrosis

  • Foreign body aspiration

  • Adenoviruses

  • Respiratory syncytial virus

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Diagnosis

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Laboratory Findings
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  • WBC counts of 20,000–30,000/μL with 70–80% lymphocytes typically appear near the end of the catarrhal stage; and the degree of lymphocytosis correlates with the severity of disease

  • Severe pulmonary hypertension and hyperleukocytosis (> 70,000/μL) are associated with severe disease and death in young children with pertussis

  • Many older children with mild infections never demonstrate lymphocytosis

  • Identification of B pertussis by culture or PCR from nasopharyngeal swabs or nasal wash specimens proves the diagnosis

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Imaging
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  • Chest radiograph reveals thickened bronchi and sometimes shows a "shaggy" heart border

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Treatment

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General Measures
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  • Nutritional support during the paroxysmal phase is important

  • Frequent small feedings, tube feeding, or parenteral fluid supplementation may be needed

  • Minimizing stimuli that trigger paroxysms is probably the best way of controlling cough

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Specific Measures
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  • Antibiotics may ameliorate early infections but have no effect on clinical symptoms in the paroxysmal stage

  • Azithromycin is the drug of choice because it promptly terminates respiratory tract carriage of B pertussis. Azithromycin is often preferred due to ease of compliance and decreased gastrointestinal side effects

  • Clarithromycin may also be used

  • Erythromycin given 4 times daily for 14 days is acceptable but not preferred; has been associated with pyloric stenosis in infants younger than 1 month

  • Ampicillin (100 mg/kg/d in four divided doses) may also be used for erythromycin-intolerant patients; recommended for therapy or prophylaxis in ...

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