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| CASE REPORT |
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| Year : 2020 | Volume
: 7
| Issue : 5 | Page : 276-278 |
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Pertussis: Resurgence of a forgotten entity
Mukesh Kumar Jain, Sibabratta Patnaik, Bandya Sahoo, Reshmi Mishra
Department of Pediatrics, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, Odisha, India
| Date of Submission | 03-May-2020 |
| Date of Decision | 28-May-2020 |
| Date of Acceptance | 05-Jun-2020 |
| Date of Web Publication | 14-Sep-2020 |
Correspondence Address:
Dr. Bandya Sahoo
Department of Pediatrics, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar . 751 024, Odisha
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JPCC.JPCC_79_20
Pertussis is a serious and life-threatening infection of infancy. Recurrent apnea with a paroxysm of cough is the early clue for its diagnosis. The rate of pertussis increased worldwide with the occurrence of regular outbreaks globally, including India. The resurgence of pertussis is multifactorial, and it includes antigenic shifts in bacteria, decreasing vaccine immunity, reduced duration of protection by acellular pertussis vaccine, and improved method of surveillance and diagnosis. Family members, especially mothers and siblings, are an important source of pertussis transmission to vulnerable infants. Maternal vaccination for pertussis during pregnancy should be done as many cases of infantile pertussis was found before primary immunization. A 45 days infants admitted to the pediatric intensive care unit with recurrent apnea and bradycardia, require prolonged mechanical ventilation with intense cardiorespiratory monitoring. Real-time polymerase chain reaction of the nasopharyngeal swab for pertussis was positive. Successfully discharged after a long course of hospitalization.
Keywords: Apnea, infancy, pertussis, polymerase chain reaction
How to cite this article:
Jain MK, Patnaik S, Sahoo B, Mishra R. Pertussis: Resurgence of a forgotten entity. J Pediatr Crit Care 2020;7:276-8 |
| Introduction | |  |
Pertussis is a serious infection with high mortality in infancy. Although a vaccine-preventable disease, its remains a significant public health threat as a reemerging infection. Over the last few decades, the incidence of pertussis increased among young adults and its a matter for grave concern.[1],[2] Parents, especially mothers and siblings have been implicated as important sources of pertussis transmission in vulnerable infants.[3] Recently, many public health studies have suggested that maternal immunization during pregnancy can decrease pertussis in infants in a cost-effective manner.[1],[4] Although the exact cause of resurgence is not clear, various factors such as antigenic shifts in bacteria, waning vaccine immunity, reduced duration of protection by acellular pertussis vaccine, and improved method of surveillance and diagnosis are held responsible.[5] Here, we describe a case of infant pertussis with the classical presentation.
| Case Report | | |
A 45 days, 3.5 kg female, twin 2 presented to the emergency with the complaints of cough for 3 days, decreased feeding, and breathing difficulty for 1 day. She was born at 36 weeks (late preterm) with a birth weight of 2 kg, with uneventful postnatal history, was feeding well and healthy till the 42nd day of life. On examination, she was sick looking, irritable with tachypnea (respiratory rate-70/min) and subcostal retraction, SpO2 was 90% on room air and heart rate of 180/min. She had coarse crackles on the left side. The patient was shifted to the pediatric intensive care unit and was treated as a case of severe pneumonia with intravenous fluid, oxygen, and antibiotics. Initial investigation revealed Hb-13.5 g/dl, Total Leukocyte count (TLC) of 18,000/uL with 72% neutrophils and 29% lymphocyte, platelet-3.7 lakh/Cumm, C-reactive protein (Q)-14.9 mg/l, and chest X-ray showed bilateral infiltrate.
On day 2, the patient having repeated episodes of seizures, desaturation, and apnea. Gradually the severity and frequency of apnea increased, requiring bag and mask ventilation. Blood gas and sugar were normal during such episodes. On day 3 of admission, the patient continued to have recurrent life-threatening apnea, bradycardia accompanied by paroxysmal cough, which requires intubation, and mechanical ventilation. 2 D echo was structurally normal with moderate pulmonary arterial hypertension (PAH). Neurosonogram and cerebrospinal fluid study are normal. Serum procalcitonin was negative (0.22 ng/ml). Blood culture revealed no growth after 48 h. Repeat hemogram on day 4 showed Hb-13 gm/dl, TLC-12,600/uL with predominant lymphocytosis 69%, and on day 5 showed a similar trend with Hb-13 g/dl, TLC-7660/uL with lymphocytes 70. On day 5 of admission, pertussis was suspected because of recurrent apnea with predominant lymphocytosis. However, a positive history of contact from either parent could not be obtained. Nasopharyngeal swab for pertussis polymerase chain reaction (PCR) was sent, and azithromycin was started. There was no clinical evidence of gastroesophageal reflux, such as persistent vomiting, arching, or failure to gain weight. The patient continued to have frequent episodes of desaturation and bradycardia on mechanical ventilation. Gradually over 2 weeks, the frequency of apnea and desaturation reduced, and the baby was extubated. Postextubation, patient was hemodynamically stable and tolerated oral feeds. The patient was discharged after 24 days of hospital stay with stable vitals and intermittent cough. PCR for pertussis was came out to be positive.
| Discussion | | |
Severe cases of Bordetella pertussis manifest with recurrent episodes of apnea along with bradycardia, desaturation, and sudden death have been reported.[6],[7] Unvaccinated newborn babies and young infants, as in our case, are at more risk. Two-thirds of all infants admitted to the hospital have apnea as it is a major symptom of pertussis.[1] Once infants develop apnea with pertussis, it is usually recurrent in nature and lasting for a prolonged period, the median duration of 19 days (range: 1–76 days).[8] Although numerous virulence factors of B. pertussis, such as pertussis toxin and adenylate cyclase toxin have been identified, the exact pathogenesis of apnea in pertussis is not yet clear.[9] Therefore, the management of patients with recurrent apnea needs early diagnosis and intense cardiorespiratory monitoring for a better outcome.
Central nervous system dysfunction such as seizures, encephalopathy is found in 10%–20% of cases, whereas hyperleukocytosis in 21%–35% of cases.[10] PAH was found in 33% of cases, and it is possibly due to obstruction of pulmonary vasculature by excessive lymphocytes in pertussis. Mortality in critical pertussis varies between 4.8% and 55%.[11] The predictors of mortality include younger age, comorbidities, need for ventilation, inotropes use, PAH, and a fast course.[11]
Bordetella pertussis is a human-specific, Gram-negative, pleomorphic, aerobic coccobacillus that is transmitted through droplets. This microorganism grows on Bordet–Gengou medium between 35°C and 37°C. Although many serological tests are available, they are not always helpful, and therefore specific test like PCR is required for better results.[7] Lymphocytosis is a major and useful diagnostic clue for pertussis infection in infants and young children.[12] However, some infants may have normal lymphocyte counts in the early stage of the disease, as seen in our cases.[13] Lymphocytosis is also a marker of disease severity and is associated with a bad prognosis in infants and may responsible for the development of pulmonary hypertension or the need for extracorporeal membrane oxygenation.[10]
Antibiotic is not helpful either in treating recurrent apnea or in changing the course of the diseases but only reduces the risk of disease transmission. Macrolide such as azithromycin is recommended for 5 days as the first-line antibiotic.[13] No effective treatment has been established for repetitive apnea caused by pertussis. Therefore, this disease needs intense cardiorespiratory monitoring for a better outcome in infancy.
The rate of pertussis is increasing worldwide, with regular upsurge being reported globally, including India.[14],[15] The resurgence of a vaccine-preventable disease such as pertussis causing increasing hospitalization, costs, and mortality is a worrisome trend and has led to calls for a relook of immunization schedules[14],[15] Critical pertussis occurring before primary immunization highlights the importance of maternal immunization against pertussis.
| Conclusion | | |
Recurrent apnea with paroxysmal cough is early sign to suspect pertussis in early infancy. Common sources of infections are family members, especially mothers and siblings. Intensive cardiorespiratory monitoring is of paramount importance. Azithromycin is the drug of choice, but it only prevents further transmission. Antepartum immunization of mothers will be perhaps helpful to prevent such infections.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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