Practice Lesson of the Week

Rapidly fatal invasive pertussis in young infants—how can we change the outcome?

BMJ 2008; 337 doi: http://dx.doi.org/10.1136/bmj.39575.715787.80 (Published 28 November 2008) Cite this as: BMJ 2008;337:a343
  1. U Theilen, consultant1,
  2. E D Johnston, specialist registrar2,
  3. P A Robinson, clinical fellow1
  1. 1Paediatric Intensive Care Unit, Royal Hospital for Sick Children, Edinburgh EH9 1LF
  2. 2Medical Paediatrics, Royal Hospital for Sick Children, Edinburgh EH9 1LF
  1. Correspondence to: U Theilen ulf.theilen{at}luht.scot.nhs.uk
  • Accepted 6 February 2008

Prevention of infection may be the only effective intervention against whooping cough for unimmunised infants

Although vaccination of infants has greatly reduced morbidity and mortality in children,1 the incidence of pertussis is rising in the non-paediatric population.2 In adults persistent cough for more than two weeks is the cardinal feature of pertussis, but with a wide differential and an atypical course, pertussis is often undiagnosed.3 Infectious adults in a family are the main source of infection for unimmunised infants.4 We report two fatal cases of invasive pertussis in unvaccinated infants.

Case reports

Case 1

A 1 month old boy presented to a district general hospital with a five day history of cough, runny nose, and difficulty feeding. A working diagnosis of bronchiolitis was made.

Both parents and an older sibling reported coughing episodes for the preceding fortnight. The baby’s mother gave a history of vomiting after these spells, and classic bouts with “whoop” were observed. The sibling had been fully vaccinated. The practice searched unsuccessfully for the childhood vaccination status of the parents, but the mother had received a pertussis booster in 1986.

On admission the baby was tachypnoeic (50 breaths per minute) with moderate subcostal recession. Oxygen saturation was 91% in air. He was tachycardic (165 beats per minute), but other observations were normal. A chest radiograph (see figure) showed increased perihilar markings. Total white cell count was raised (74 000×109/l (normal 6000-18 000×109/l)), with 38 500×109/l lymphocytes (normal 3000-13.5 000×109/l).

Pertussis was considered and erythromycin was started. Over the next 24 hours the child developed coughing spells with profound apnoeas. He was intubated and transferred to a paediatric intensive care unit.

Left chest radiograph taken when the baby was admitted. It shows central peribronchial thickening only …

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