Case Based Presentation

Sian Chess-Williams

Contents

• Case: history, examination & investigations• Diagnosis & Management.• Vaccine• Conclusion• References

History

• A&E admission• 2 month old girl• PC – spasmodic cough 1/52• HPC: becomes purple/red in face with cough

and vomiting after coughing 4/7. “struggles to catch breathe”. Also has been snuffley. No apnoea or cyanosis. No fever. Passing urine fine. Bowels fine. Feeding well 210ml 3-4 hourly (275ml/kg/day)

History

• Birth Hx / PMH: Term + 10, induced NVD• FH: mum & daughter have had cough & cold.• SH: lives with mum, dad, 3 siblings (age 1, 3, &

4 years) – not had imms• Immunisations: not had any yet• Development: no worries• Medication: nil, no allergies.

Examination

• Temp 36 ⁰C, RR 38, HR 162, Sats 96% air• Alert & active• Chest clear, no respiratory distress• HS 1+2+0, cap refill < 2 secs, femorals ++• Abdo soft, no hepatosplenomegaly• Anterior fontanelle normotensive• Mucous membranes moist• Good tone, sucking & grasping reflexes present.• No rash / bruising.

Investigations

• Nasal swab• NPA• SATs monitor• Oral Erythromycin • Decrease feeds from 7 to 5 oz• CXR• Bloods FBC, U&E, CRP• NG feeds

Investigations

• Nasal swab• NPA: RSV negative• SATs monitor (drop to 74% during a paroxysm of

coughing).• Oral Erythromycin • Decrease feeds from 7 to 5 oz• CXR: NAD• Bloods: WCC 34, lymphocytes 21.7, CRP < 1• NG feeds

Whooping cough

• Bacterium Bordetella pertussis.• Most infectious during the prodromal phase

(coryza) & is infectious for up to 3 weeks.• Affects any age, but infants less than 6 months

are at the greatest risk of complications.• Mortality: 1 in 200 if < 6 months old.

Whooping cough

• Prodromal phase – nasal discharge & cough lasting a few days.

• Paroxysmal phase - Prolonged paroxysms of coughing +/- vomiting and terminated by a characteristic inspiratory whoop.

• Complications: apnoea, severe pneumonia, encephalopathy, death

Management

• Hospital admission for supportive therapy if needed.

• Macrolide antibiotics (erythromycin) reduce the period of infectivity.

• Avoid creche, school, ect until had at least 5 days of Abx or had illness for at least 21 days.

• Household contacts also treated to reduce spread of infection.

• Notifiable disease

2 months 1.Diphtheria, tetanus, pertussis, polio andHaemophilus influenzae type b (DTaP/IPV/Hib)

2.Pneumococcal conjugate vaccine (PCV)

1.One injection (Pediacel®)

2.One injection (Prevenar13®)

3 months 1.Diphtheria, tetanus, pertussis, polio and H. influenzae type b (DTaP/IPV/Hib)

2.Meningitis C (MenC)

1.One injection (Pediacel®)

2.One injection (NeisVac-C® or Meningitec®)

4 months 1.Diphtheria, tetanus, pertussis, polio and H. influenzae type b (DTaP/IPV/Hib)

2.Pneumococcal conjugate vaccine (PCV)

3.Meningitis C (MenC)

1.One injection (Pediacel®)

2.One injection (Prevenar 13®)

3.One injection (NeisVac-C® or Meningitec®)

3 years and 4 months orsoon after

1.Diphtheria, tetanus, pertussis and polio (dTaP/IPV or DTaP/IPV)

2.Measles, mumps and rubella (MMR)

1.One injection (Repevax® or Infanrix-IPV®)

2.One injection (Priorix® or MMR II®)

Vaccine

• Incidence and severity is greatly reduced by the pertussis vaccine.

• Increased herd immunity reduces transmission to young babies from older siblings and adults.

• Diphtheria/tetanus/acellular pertussis/inactivated polio vaccine/Haemophilus influenzae type b (DTaP/IPV/Hib)

• This Pediacel® vaccine contains 5 purified pertussis components of the Bordetella Pertussis organism.

Vaccine

• Vaccine side effects: minor local reaction (swelling, redness, discomfort) in 15% of recipients.

• Do not give if past history of anaphylactic reaction to previous pertussis containing vaccine, neomycin, streptomycin or polymyxin B. Risk of anaphylactic reaction <3 per million doses.

• Do not give if child has an evolving neurological condition or current neurological deterioration.

Vaccine

• From the mid-1990s, uptake has consistently been over 90%. In 2008 there were 244 cases of whooping cough reported between April and June.

Conclusion

• Whooping cough is preventable.• It can have serious complications including

death.• Management is only supportive.• The majority need to be vaccinated to help

protect those too young to be vaccinated.

Any questions

References• Bohlke K, Davis RL, Marcy SM, et al; Risk of anaphylaxis

after vaccination of children and adolescents. Pediatrics. 2003 Oct;112(4):815-20. [abstract]

• Miller E; Overview of recent clinical trials of acellular pertussis vaccines. Biologicals. 1999 Jun;27(2):79-86. [abstract]

• HPA - Whooping Cough (Pertussis). Health Protection Agency.

• Patient UK website: vaccines.• D. M. Roberton, M South;Practical paediatrics. Sixth

edition. 2007.