Whooping cough

Question 1

What is the causative agent of Whooping cough (pertussis)?

Answer 1

Whooping cough is caused by the Gram-negative bacterium Bordetella pertussis.

Question 2

How many cases of Whooping cough are reported annually in the UK?

Answer 2

Approximately 1,000 cases of Whooping cough are reported each year in the UK.

Question 3

What are the routine immunization ages for infants against Whooping cough?

Answer 3

Infants are routinely immunized against Whooping cough at 2, 3, 4 months, and a booster at 3-5 years.

Question 4

What is the common nickname for Whooping cough due to its duration?

Answer 4

Whooping cough is sometimes called the ‘cough of 100 days’.

Question 5

Why are pregnant women vaccinated against Whooping cough?

Answer 5

Pregnant women are vaccinated to protect newborn infants, who are particularly vulnerable to Whooping cough.

Question 6

Does infection or immunization provide lifelong protection against Whooping cough?

Answer 6

Neither infection nor immunization results in lifelong protection against Whooping cough.

Question 7

What are the phases of Whooping cough?

Answer 7

The phases of Whooping cough are: catarrhal phase (1-2 weeks), paroxysmal phase (2-8 weeks), and convalescent phase (weeks to months).

Question 8

What are the symptoms of the catarrhal phase of Whooping cough?

Answer 8

Symptoms are similar to a viral upper respiratory tract infection.

Question 9

Describe the paroxysmal phase of Whooping cough.

Answer 9

The cough increases in severity, with bouts worse at night and after feeding, potentially ending in vomiting and associated central cyanosis.

Question 10

What does the convalescent phase of Whooping cough involve?

Answer 10

During the convalescent phase, the cough subsides over weeks to months.

Question 11

What are key diagnostic criteria for Whooping cough?

Answer 11

Suspect Whooping cough with a cough lasting over 14 days, plus features like paroxysmal cough, inspiratory whoop, post-tussive vomiting, or undiagnosed apnoeic attacks.

Question 12

How is Whooping cough diagnosed?

Answer 12

Diagnosis involves a per nasal swab culture for Bordetella pertussis, with PCR and serology increasingly used.

Question 13

What is the management protocol for infants with suspected Whooping cough?

Answer 13

Infants under 6 months with suspected Whooping cough should be admitted and may receive oral macrolide antibiotics.

Question 14

What are the guidelines for school exclusion with Whooping cough?

Answer 14

Exclude from school for 48 hours after commencing antibiotics, or 21 days from the onset of symptoms if no antibiotics.

Question 15

List complications of Whooping cough.

Answer 15

Complications include subconjunctival haemorrhage, pneumonia, bronchiectasis, and seizures.

Question 16

summary of whooping cough

Answer 16

Whooping cough (pertussis)

Whooping cough (pertussis) is an infectious disease caused by the Gram-negative bacterium Bordetella pertussis. It typically presents in children. There are around 1,000 cases are reported each year in the UK. It is sometimes called the ‘cough of 100 days’.

Immunisation
infants are routinely immunised at 2, 3, 4 months and 3-5 years. Newborn infants are particularly vulnerable, which is why the vaccination campaign for pregnant women was introduced
neither infection nor immunisation results in lifelong protection - hence adolescents and adults may develop whooping cough despite having had their routine immunisations

Features
catarrhal phase
symptoms are similar to a viral upper respiratory tract infection
lasts around 1-2 weeks
paroxysmal phase
the cough increases in severity
coughing bouts are usually worse at night and after feeding, may be ended by vomiting & associated central cyanosis
inspiratory whoop: not always present (caused by forced inspiration against a closed glottis)
infants may have spells of apnoea
persistent coughing may cause subconjunctival haemorrhages or even anoxia leading to syncope & seizures
lasts between 2-8 weeks
convalescent phase
the cough subsides over weeks to months

Diagnostic criteria
Whooping cough should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features:
Paroxysmal cough.
Inspiratory whoop.
Post-tussive vomiting.
Undiagnosed apnoeic attacks in young infants.

Diagnosis
per nasal swab culture for Bordetella pertussis - may take several days or weeks to come back
PCR and serology are now increasingly used as their availability becomes more widespread

Management
infants under 6 months with suspect pertussis should be admitted
in the UK pertussis is a notifiable disease
an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread
household contacts should be offered antibiotic prophylaxis
antibiotic therapy has not been shown to alter the course of the illness
school exclusion: 48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )

Complications
subconjunctival haemorrhage
pneumonia
bronchiectasis
seizures

Vaccination of pregnant women

In 2012 there was an outbreak of whooping cough (pertussis) which resulted in the death of 14 newborn children. As a temporary measure, a vaccination programme was introduced in 2012 for pregnant women. This has successfully reduced the number of cases of whooping cough (the vaccine is thought to be more than 90% effective in preventing newborns developing whooping cough). It was however decided in 2014 to extend the whooping cough vaccination programme for pregnant women. This decision was taken as there was a ‘great deal of uncertainty’ about the timing of future outbreaks.

Women who are between 16-32 weeks pregnant will be offered the vaccine.

Question 17

A nine-month-old infant is brought to the GP. His mother reports that he has had a runny nose and mild fever for around two weeks. For the past week, he has experienced severe bouts of coughing which often cause him to vomit; these bouts typically occur after feeding and at night. A review of his GP records and further discussions with his mother confirm that he has not yet received any of his routine childhood vaccinations.

Given the likely diagnosis, what is the most appropriate management?

Bed rest, fluids and ibuprofen
Intravenous ceftriaxone
Oral azithromycin
Oral phenoxymethylpenicillin
Single dose of dexamethasone

Answer 17

Oral azithromycin

Child with a persistent cough, worse at night, possibly associated with vomiting → ?whooping cough

Oral azithromycin is correct. This child’s post-tussive vomiting and vaccination status mean that pertussis, or whooping cough, is the most likely diagnosis. As this child has presented within three weeks of symptomatic onset, treatment with a macrolide antibiotic such as azithromycin is indicated in this age group.

Bed rest, fluids and ibuprofen is incorrect. Supportive care will form a part of treatment in most infectious illnesses and may be the mainstay of management when a patient with pertussis presents more than three weeks after symptomatic onset. However, this patient has presented within a fortnight of developing symptoms, so a macrolide antibiotic is indicated.

Intravenous ceftriaxone is incorrect. This is a treatment option for meningococcal meningitis, which may present with irritability, poor feeding, and a non-blanching rash in infants. The duration and nature of this patient’s symptoms mean that meningitis is unlikely here.

Oral phenoxymethylpenicillin is incorrect. This may be used in the management of tonsillitis and scarlet fever when Centor criteria are met, but is not indicated here.

A single dose of dexamethasone is incorrect. This is the recommended management of croup. Croup is characterised by a sudden-onset barking cough with stridor and respiratory distress. The duration and insidious onset of symptoms means that croup is less likely to be the cause of illness in this case.

Question 18

3.
A 3-year-old girl is brought to paediatric A&E after suffering from a severe cough. It started 2 days ago and tends to occur in abrupt bursts lasting a matter of minutes, which has once ended with her vomiting. She has had
a cold and a runny nose for the past 1 week. On examination, a subconjunctival haemorrhage is noted. What is the most likely diagnosis?

Bronchiolitis
Whooping cough
Croup
Pneumonia
Acute epiglottitis

Answer 18

Whooping cough

Whooping cough is a respiratory tract infection that is caused by Bordatella pertussis. It is becoming less common in developed countries since its introduction to the childhood vaccination schedule. It tends to initially cause a
week of coryzal symptoms (known as the catarrhal phase) followed by the development of paroxysmal bouts of coughing. They are typically worse at night and may be severe enough to cause vomiting. Gasping for air between coughs may give rise to the characteristic ‘whoop’ that gives the disease its name. Vigorous coughing can lead to nosebleeds and sub-conjunctival haemorrhages. Patients may experience bouts of coughing for up to 3 months. If patients are diagnosed within 21 days of the onset of symptoms, they may benefit from a macrolide antibiotic (e.g. azithromycin). As it is a highly contagious disease, parents should be advised to keep children away from school/nursery until 48 hours of antibiotics have been completed or until 21 days after the onset of symptoms.
Bronchiolitis tends to follow a mild, self-limiting course with coryzal symptoms and a wheeze. Furthermore, the vast majority of cases occur in patients under the age of 1 year. Croup presents with a barking cough and stridor. Pneumonia will cause a cough, fever, and increased respiratory rate. Acute epiglottitis is a potentially life-threatening condition in which there is a rapid swelling of the epiglottis caused by Haemophilus influenzae type b. Children will typically present acutely unwell with a high fever and a painful throat that limits their ability to speak or swallow. There may be a soft stridor and the child may be sitting upright, immobile, and drooling from the mouth. Fortunately, acute epiglottitis has become very rare after the introduction of the Haemophilus influenzae type b vaccine.

Question 19

A 5-year-old child presents to the paediatric clinic with a persistent cough that has been worsening over the past week. The child’s parent mentions that the cough started approximately 10 days ago and has been accompanied by episodes of coughing fits, sometimes leading to a ‘whooping’ sound at the end of each coughing episode. The child is otherwise healthy, with no significant medical history.

What is the antibiotic of choice in the treatment of this condition?

Amoxicillin
Azithromycin
Ceftriaxone
Doxycycline
Trimethoprim

Answer 19

Azithromycin

Whooping cough - azithromycin or clarithromycin if the onset of cough is within the previous 21 days

Azithromycin is correct. The child’s symptoms are suggestive of whooping cough (pertussis), an infectious disease caused by the bacterium Bordetella pertussis. The antibiotic of choice is a macrolide such as azithromycin, clarithromycin, or erythromycin. It should be given if the onset of the cough is within the previous 21 days. It is generally well tolerated.

Amoxicillin is incorrect as it does not target Bordetella pertussis which is the bacterium responsible for whooping cough, which is the diagnosis in this scenario.

Ceftriaxone is incorrect. Despite being a broad-spectrum antibiotic often used for respiratory tract infections, it is not the first line for whooping cough. The patient here requires the most effective antibiotic, which would be a macrolide.

Doxycycline is incorrect. It is not recommended for the treatment of whooping cough, particularly in those under 8 years old (this patient is 5 years old) as it can cause yellowing of the teeth and enamel issues.

Trimethoprim is incorrect, this antibiotic is not recommended in the treatment of whooping cough.

Question 20

A 5-year-old girl is brought to the GP by her mother as she has had a very loud, harsh cough for the last 2 weeks, and has been more lethargic than usual. She appears systemically well, but you witness 2 coughing fits during your consultation, in which the child appears distressed and struggles to take breaths in, making a loud harsh inspiratory noise between coughing fits. The patient has no known allergies or past medical history, but her vaccination record is unclear, having moved to the UK from abroad two years ago. Her observations reveal a fever at 37.5ºC.

What is the most appropriate management plan?

No treatment needed but report to Public Health England
Send to emergency department
Prescribe azithromycin and report to Public Health England
Prescribe azithromycin and review in 1 week
Prescribe salbutamol nebulisers

Answer 20

Prescribe azithromycin and report to Public Health England

Whooping cough is a notifiable disease

This question is testing your management of whooping cough. This is a notifiable disease and therefore Public Health England must be informed. Furthermore, NICE guidelines state that whooping cough can be treated with oral azithromycin within the first 21 days of symptoms. If the patient had presented later than this, then no antibiotic therapy would have been needed. Salbutamol nebulisers would not be appropriate as antibiotic treatment is needed.