Prolonged Cough
Answer: C
Interesting History
This man is suffering from prolonged cough, paroxysmal episodes, and post-tussive emesis. Given his symptoms, age, and waning of vaccine-induced immunity, this young man may be presenting with pertussis. Pertussis or “whooping cough” is from the Latin per “intensive” and tussis “cough”. Pertussis has plagued humanity since ancient times, and its traditional morbidity is memorialized in its various monikers world-wide: in Romance languages such as Spanish, it is referred to as “savage cough” (tos ferina); in Slavic languages such as Ukrainian, “monster cough” (кашлюк – ‘kashlyuk’), and in Asian languages such as Japanese, “100 day cough” (百日咳 – hiragana: ひゃくにちぜき; romaji: ‘hyaku nichi zeki’).
Why We Care
In neonates and infants, pertussis can be a life-threatening disease, sometimes presenting with pneumonia, apnea, seizures, or death; vaccination programs have been so successful in children under 10 years of age that the epidemiology of pertussis in the U.S. has now shifted to a reservoir of adolescents and adults. Adults should be given a booster of Tdap every 10 years (recommendations may soon change to use this as the booster both for tetanus and pertussis vaccination).
Pertussis Basics
Pertussis classically presents in three stages: coryzal (cough, coryza, rarely fever, mimicking a URI – first 1-2 weeks); paroxysmal (increasing frequency and severity of cough, often in violent, prolonged jags – 2-6 weeks); and convalescent (slowly improving, but lingering cough – up to ‘hyaku nichi’ – 100 days!).
Pertussis is difficult to distinguish from simple URI in the coryzal stage; lamentably, this unclear phase is when antimicrobial treatment may actually affect the course and duration of the disease. Children, adolescents, and adults are treated at any stage (regardless of length of symptoms) as a public health measure: 5 days of therapy greatly diminishes infectivity, if not duration of symptoms (C). This is especially salient when the infected is close to infants, pregnant women, the chronically ill, or the elderly.
Various features in history and physical examination have been studied to predict pertussis. A recent systematic review revealed that individual features had less-than-ideal performance in LRs: post-tussive emesis – LR 1.8; [95% CI 1.4 to 2.2]; inspiratory whoop – LR 1.9 [95% CI 1.4 to 2.6]; absence of these features (LR-) performed poorly. No study has examined the performance of combined features.
Unfortunately, laboratory confirmation with PCR or serology is not readily available in the ED; the Centers for Disease Control and Prevention (CDC) recommend that if the threshold for screening/testing is met, then the threshold for treatment is met. In other words, if you suspect pertussis, strongly consider simply treating it. Confirmation may be made with laboratory investigation (culture or PCR initially, serology only after 4 weeks of symptoms), and confirmed cases should be reported to the local health authority.
Incorrect Answers
A single dose of Penicillin G IM is used in the treatment of group A Streptococcal pharyngitis (A).
Oseltamivir (Tamiflu) is used in the treatment of influenza A or B. This season’s recommendations (2012-2013) are to treat high-risk groups ideally within 48 hours (but may be considered further in the course of illness) or anyone hospitalized with influenza, regardless of onset of symptoms. High-risk individuals are: children < 2 years of age, adults 65 or older, and anyone with comorbidities such as pulmonary disease (including asthma), metabolic disorders (including diabetes mellitus), cardiovascular disease (excluding lone hypertension), neurologic disease (stroke, cerebral palsy, other functional impairments), renal disease, hepatic disease, hematologic disorders (including sickle cell disease), the morbidly obese (BMI > 40), pregnant women (up to 2 weeks postpartum), children under 19 on chronic aspirin therapy, Alaskan Natives or Native Americans, and residents of skilled nursing facilities.
Ondansetron (Zofran) is a useful adjunct for the treatment of nausea (D). Although this may be given to this patient, post-tussive emesis is mainly mechanical in nature: increased intrathoracic pressures cause an increase in extragastric pressure, causing regurgitation.
Bottom line:
During epidemics, treat if there is suspicion as early as possible. Otherwise, treat the patient with a cough lasting more than 2 weeks with one or more of the following:
References:
From the 2013 ABEM LLSA reading list:
Cornia PB, Hersh AL, Lipsky BA, Newman TB, Gonzales R. Does this coughing adolescent or adult patient have pertussis? JAMA. 2010;304(8):890-896.
CDC website:
http://www.cdc.gov/flu/index.htm
CDC website:
http://www.cdc.gov/pertussis/
How properly to collect a nasopharyngeal swab specimen:
Video below
(You can comfortably skip to 1:50 and watch from there.)
Interesting History
This man is suffering from prolonged cough, paroxysmal episodes, and post-tussive emesis. Given his symptoms, age, and waning of vaccine-induced immunity, this young man may be presenting with pertussis. Pertussis or “whooping cough” is from the Latin per “intensive” and tussis “cough”. Pertussis has plagued humanity since ancient times, and its traditional morbidity is memorialized in its various monikers world-wide: in Romance languages such as Spanish, it is referred to as “savage cough” (tos ferina); in Slavic languages such as Ukrainian, “monster cough” (кашлюк – ‘kashlyuk’), and in Asian languages such as Japanese, “100 day cough” (百日咳 – hiragana: ひゃくにちぜき; romaji: ‘hyaku nichi zeki’).
Why We Care
In neonates and infants, pertussis can be a life-threatening disease, sometimes presenting with pneumonia, apnea, seizures, or death; vaccination programs have been so successful in children under 10 years of age that the epidemiology of pertussis in the U.S. has now shifted to a reservoir of adolescents and adults. Adults should be given a booster of Tdap every 10 years (recommendations may soon change to use this as the booster both for tetanus and pertussis vaccination).
Pertussis Basics
Pertussis classically presents in three stages: coryzal (cough, coryza, rarely fever, mimicking a URI – first 1-2 weeks); paroxysmal (increasing frequency and severity of cough, often in violent, prolonged jags – 2-6 weeks); and convalescent (slowly improving, but lingering cough – up to ‘hyaku nichi’ – 100 days!).
Pertussis is difficult to distinguish from simple URI in the coryzal stage; lamentably, this unclear phase is when antimicrobial treatment may actually affect the course and duration of the disease. Children, adolescents, and adults are treated at any stage (regardless of length of symptoms) as a public health measure: 5 days of therapy greatly diminishes infectivity, if not duration of symptoms (C). This is especially salient when the infected is close to infants, pregnant women, the chronically ill, or the elderly.
Various features in history and physical examination have been studied to predict pertussis. A recent systematic review revealed that individual features had less-than-ideal performance in LRs: post-tussive emesis – LR 1.8; [95% CI 1.4 to 2.2]; inspiratory whoop – LR 1.9 [95% CI 1.4 to 2.6]; absence of these features (LR-) performed poorly. No study has examined the performance of combined features.
Unfortunately, laboratory confirmation with PCR or serology is not readily available in the ED; the Centers for Disease Control and Prevention (CDC) recommend that if the threshold for screening/testing is met, then the threshold for treatment is met. In other words, if you suspect pertussis, strongly consider simply treating it. Confirmation may be made with laboratory investigation (culture or PCR initially, serology only after 4 weeks of symptoms), and confirmed cases should be reported to the local health authority.
Incorrect Answers
A single dose of Penicillin G IM is used in the treatment of group A Streptococcal pharyngitis (A).
Oseltamivir (Tamiflu) is used in the treatment of influenza A or B. This season’s recommendations (2012-2013) are to treat high-risk groups ideally within 48 hours (but may be considered further in the course of illness) or anyone hospitalized with influenza, regardless of onset of symptoms. High-risk individuals are: children < 2 years of age, adults 65 or older, and anyone with comorbidities such as pulmonary disease (including asthma), metabolic disorders (including diabetes mellitus), cardiovascular disease (excluding lone hypertension), neurologic disease (stroke, cerebral palsy, other functional impairments), renal disease, hepatic disease, hematologic disorders (including sickle cell disease), the morbidly obese (BMI > 40), pregnant women (up to 2 weeks postpartum), children under 19 on chronic aspirin therapy, Alaskan Natives or Native Americans, and residents of skilled nursing facilities.
Ondansetron (Zofran) is a useful adjunct for the treatment of nausea (D). Although this may be given to this patient, post-tussive emesis is mainly mechanical in nature: increased intrathoracic pressures cause an increase in extragastric pressure, causing regurgitation.
Bottom line:
During epidemics, treat if there is suspicion as early as possible. Otherwise, treat the patient with a cough lasting more than 2 weeks with one or more of the following:
- Paroxysms of coughing
- Post-tussive emesis
- Inspiratory whoop
References:
From the 2013 ABEM LLSA reading list:
Cornia PB, Hersh AL, Lipsky BA, Newman TB, Gonzales R. Does this coughing adolescent or adult patient have pertussis? JAMA. 2010;304(8):890-896.
CDC website:
http://www.cdc.gov/flu/index.htm
CDC website:
http://www.cdc.gov/pertussis/
How properly to collect a nasopharyngeal swab specimen:
Video below
(You can comfortably skip to 1:50 and watch from there.)