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.