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42 do term female with a Hx of negative sepsis work up @ 17 daysof life (rectal temp100.7).

Now with 10 days of cough, poor feeding, weight loss, irritabilityand some episodes of emesis with coughing.

Seen @ UrgentCare for mild respiratory distress and worseningcough. Received albuterol nebx1 with no improvement 3 days PTA.

Had 4 episodes of cough spasms resulting in blue lips and

gagging. Pt seemed less alert during spasms. Mother gave heramoxicillin.

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PMH: Born @ 40 weeks. Home birth with minimal prenatal care.

GBS unknown. Mother HIV negative.

PSH: No surgeries

IMMS: None

MEDS: None

ALLERGIES: NKDA

DIET: Breast milk exclusively

FH: Asthma and eczema. Mother had cold symptoms shortly aftergiving birth to the patient.

SH: Lives with mom, dad, and brother (unimmunized). Doesntattend daycare.

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VITAL SIGNS: T 37.8, HR168, RR 69, Sat O2 89% W:4.1 kg.

GENERAL: Awake and alert. Mild distress. Episodic periods of coughing(~30 seconds).

HEENT: N/A, conjunctivae clear, PERRL. TMs are clear with normallandmarks, no rhinorrhea. MMM, OP normal.

NECK: No swollen or tender lymph nodes. Supple with full range ofmotion.

LUNGS: Coarse breath sounds, no wheezing, no crackles, mild subcostaland intercostal retractions

CV: Tachycardic, no murmurs, pulses 2+, cap refill 2 secs.

GI: Soft, nontender, nondistended. No HSM. BS+

SKIN: no rashes, no cyanosis, no jaundice NEURO: Grossly normal strength and tone, patellar tendon reflexes

normal. No motor deficits.

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CXR: Right upper lobe infiltrates CBC: WBC 48,000 (3%B, 26%N, 68%L)

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Adenovirus Pertussis C. pneumonia M. pneumonia Asthma

Bronchiolitis Bacterial pneumonia Cystic fibrosis Fungal pulmonary infections Tuberculosis

GERD Sinusitis Foreign body

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RSV negative, VRP negative BMP normal

Blood cx, Pertussis, C. pneumoniaeand MycoplasmaPCR sent

Admitted to the floor on 1L NC. Started on Ceftriaxone andazithromycin.

Next day: RR 100, Sat O2 88% on FM FiO2 100%

CBG: 7.16/82

Intubated -> PICU

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Developed poor perfusion, hypotension that didntrespond to IVF and only partially to inotropics.Persistent hypoxemia.

ECHO: Dilated right ventricle and severe pulmonary

hypertension

Repeat WBC 99,000 (72% L)

Fatal cardiac arrest

Pertussis PCR (nasopharyngeal and tracheal aspirate) :POSITIVE

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Bordetella pertussis

Primarily a toxin-mediated disease.

The bacteria: Attaches to the cilia of the

respiratory epithelial cells.

Produces toxins thatparalyze the cilia.

Causes inflammation of the

respiratory tract (interfereswith the clearing ofsecretions)

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No seasonal pattern, however in North Americausually occurs in the summer and fall

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Incubation 6 to 20 days In the youngest infants, atypical presentation is common . Cough may be

minimal or absent and the primary symptom can be .

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In infants 12 mo who get Pertussis, more than50% need to be hospitalized. 50% will have apnea 20% pneumonia 1% seizures 1% will die 0.3% will have encephalopathy (hypoxia from coughing or

possibly from toxin)

Other complications : anorexia, dehydration,difficulty sleeping, epistaxis, hernias, otitis media,

urinary incontinence, pneumothorax, rectalprolapse, rib fractures, syncope and subduralhematomas.

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Patients present with and developand that is

unresponsive to maximal intensive care.

from the raised white blood cell (WBC)

count

WBC counts of >100 000/L have been associated with auniformly fatal course with conventional treatment.

ECMO, pulmonary artery vasodilators are usually not effective

Leukocyte reducing measures: exchange transfusion orleukofiltration

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The CDC recommends treating patients with Pertussis oftest results.

Isolation precautions should be in effect until of effective therapy Treat persons aged >1 year within 3 weeks of cough onset Treat infants aged persons 1 mo. For infants

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