A Boy with Coughing Spells

Posted by • February 20th, 2015

In the latest Case Record of the Massachusetts General Hospital, a 16-year-old boy presented with a 3-week history of cough and nasal congestion and a 3-day history of severe coughing spells, post-tussive emesis, and trouble breathing. A chest radiograph was normal. A diagnostic test was performed.

Since the mid-1980s, there has been a gradual upward trend in the incidence of pertussis, punctuated by spikes in outbreaks every 2 to 5 years — including in 2012, when more than 48,000 cases were reported in the United States, and in 2014, when approximately 10,000 were reported in California.

Clinical Pearls

What conditions are included in the differential diagnosis for chronic cough?

Recurrent infection is the most frequent cause of prolonged (subacute or chronic) cough in children. Common causes of prolonged cough include asthma, gastroesophageal reflux disease, and the upper-airway cough syndrome. Other causes include passive or active smoking, cystic fibrosis, foreign-body aspiration, extrinsic airway compression, and interstitial lung disease. Pyogenic bacterial pneumonia or prolonged bacterial bronchitis can cause persistent cough. Tuberculosis can manifest as subacute or chronic cough.
Mycoplasma pneumoniae is a common cause of both upper and lower respiratory tract infections, especially in children and young adults. Onset of symptoms is often gradual and characterized by fever, headache, malaise, and cough that increases in severity over several days. Chlamydophila pneumoniae can cause similar upper and lower respiratory tract infections, including an atypical pneumonia syndrome. Several respiratory viral infections are associated with cough, which may be prolonged. Influenza can cause cough, with or without frank pneumonia. Adenovirus also causes acute respiratory disease, often with coryza and sore throat. The cough associated with rhinovirus often develops after the onset of nasal symptoms and persists after nasal symptoms have resolved. Respiratory syncytial virus is best known as a cause of bronchiolitis in infants but can also result in upper respiratory tract infection and cough in patients of all ages; in otherwise healthy children and young adults, symptoms are usually mild. Parainfluenza virus may cause an infection, usually an upper respiratory infection with a cough, in older children.

Table 1. Some Causes of Prolonged Cough in Children.

What are the clinical features of , including its associated cough?

An unimmunized person with pertussis first presents with rhinorrhea, conjunctival irritation, and mild cough, with little or no fever. After 7 to 10 days, this catarrhal phase transitions to the paroxysmal phase, and the cough becomes more frequent and severe. Typical paroxysms consist of a series of several forceful coughs during a single expiration, followed by gasping inhalation; this can result in a whooping sound, especially in young children. Post-tussive vomiting is common among affected patients. Paroxysms may occur several times an hour and can be more prominent at night.
Patients are usually asymptomatic between paroxysms. After several weeks, the cough gradually diminishes. Infection in infants can manifest as apnea, with or without cough. Adolescents and adults with pertussis who have been previously immunized sometimes do not have the classic paroxysms; rather, the illness is characterized primarily by persistent cough and can be complicated by syncope, rib fracture, incontinence, pneumonia, seizures, or encephalopathy.

Morning Report Questions

Q: What duration of protective immunity is provided by the DTaP and Tdap vaccines?

A: It has become clear that the immunity evoked by the DTaP vaccine (an acellular pertussis vaccine), which has been in wide use since the late 1990s, is less durable than the immunity evoked by the diphtheria-tetanus-whole-cell pertussis (DTwP) vaccine. Studies have shown that the protective immunity evoked by DTaP wanes rapidly, with vaccine efficacy decreasing within 5 years after the final childhood dose is administered, at 4 to 6 years of age. Studies have also confirmed that adolescents who received only the DTaP vaccine have a substantially higher risk of contracting pertussis than do adolescents who had received any dose of the DTwP vaccine. The lowercase “d” and “p” in Tdap signify that the vaccine has a low dose of the diphtheria and pertussis components, as compared with the DTaP vaccine. Two of three studies that examined the efficacy of the Tdap vaccine showed significant efficacy in the first 2 years after vaccination.

Table 3. Efficacy Studies of the Tetanus Toxoid-Reduced Diphtheria Toxoid-Acellular Pertussis, Adsorbed (Tdap) Vaccine.

Q: Who should receive the Tdap vaccine?

A: Currently, the ACIP [Advisory Committee on Immunization Practices] recommends administering the Tdap vaccine only once and subsequently administering the tetanus-diphtheria (Td) vaccine every 10 years, as well as administering the Tdap vaccine to pregnant women. A single dose of Tdap is recommended for children 11 or 12 years of age and for adolescents or adults who have not previously received it. The Tdap vaccine may be administered regardless of the time since the last vaccine containing tetanus and diphtheria was administered. The ACIP also recommends the Tdap vaccine for persons 7 years of age or older who are not fully immunized with the DTaP vaccine.

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