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Good Morning!. Friday, August 3 rd 2012. Semantic Qualifiers. Illness Script. Predisposing Conditions Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc) Pathophysiological Insult

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Good Morning!

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  1. Good Morning! Friday, August 3rd 2012

  2. Semantic Qualifiers

  3. Illness Script • Predisposing Conditions • Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc) • Pathophysiological Insult • What is physically happening in the body, organisms involved, etc. • Clinical Manifestations • Signs and symptoms • Labs and imaging

  4. Predisposing Conditions: Pertussis • Highest incidence • Infants <6mos (not completely immunized) • Adolescents (due to waning immunity) • Important infectious source for infants/children • Risk factors • Childcare, school outbreaks • Sick caregiver

  5. Pathophysiology: Pertussis • Organism: Bordetellapertussis • Gram-negative pleomorphic bacillus • Bordetellaparapertussis– milder disease • Transmitted via coughing (aerosolized droplets) • Infect ciliated epithelium of respiratory tract • Toxins cause local and systemic effects • Plugs of necrotic bronchial epithelial tissues and thick mucus in airways • VERY contagious during earliest (catarrhal) stage

  6. Clinical Manifestations: Pertussis • Classic pertussis syndrome (ages 1-10yrs)** • 3 stages • Catarrhal – nonspecific signs; lasts 1-2 weeks • Nasal congestion, rhinorrhea, sneezing, tearing, low-grade fever • Paroxysmal – most distinctive stage; lasts 2-4 weeks • Paroxysms of coughing during expiration • Forceful inhalation “whoop” • http://www.pkids.org/diseases/pertussis.html • Post-tussive emesis • Convalescent – resolution of symptoms; lasts 1-2 weeks • Coughing becomes less severe; whoops disappear • Residual cough may last for months

  7. Clinical Manifestations: Pertussis • Infants: not classic** • Apnea (can hypoxia leading to CNS damage) • No classic “whoop” • Secondary bacterial pneumonia common • Adolescents/adults: not classic** • Prolonged bronchitis-like illness • Persistent, nonproductive cough • Begins as nonspecific URI • Generally do not have “whoop”, but will have paroxysms of cough • Cough lasts weeks-months

  8. Diagnosis** • Definitive diagnosis based on culture of B. pertussisfrom nasopharyngeal specimen • VERY difficult to isolate • DFA of nasopharyngeal secretions • Technically difficult; low sensitivity (~60%) • PCR is the preferred method • More sensitive and specific • CBC: marked leukocytosis and lymphocytosis

  9. Treatment** • Age < 6 months: strongly consider admit • Close monitoring (cyanosis, apnea), frequent suctioning, O2, IVFs, nutrition • Antibiotics • 1st line: macrolide • 2nd line: TMP-SMX • Early treatment (catarrhal stage) eradicates nasopharygeal carriage, shortens duration of illness • However, treatment during the paroxysmal stage does NOT alter the clinical course • Does reduce the spread of secondary cases • Can return to school after treatment x 5 days

  10. Treatment

  11. Prophylaxis** • ALL close contacts should receive prophylaxis (including child care/school contacts) • Antibiotics • Same agents, dose, duration as for treatment of pertussis • Best if within 21 days of onset of cough in index case • Immunization • Close contacts who are unimmunized or underimmunized should also have pertussis vaccine initiated or continued immediately • DTaP: for children <7 years old • Tdap: for children ages >7 years old

  12. Routine Pertussis Vaccine Recommendations • DTaP: 5 doses • 2months, 4months, 6months, 15-18months, 4-6years • Tdap: 1 dose • 11-12years • Immunization with Tdap (if not received previously) is recommended for adults who will have close contact with an infant aged <12 months (at least 2 weeks prior to contact with the infant) • Contraindications for pertussis vaccine**: • Allergic reaction, unstable or active CNS disease, encephalopathy within 7 days of receiving prior pertussis vaccine

  13. Waning Immunization** • Neither infection with active disease or vaccination provides complete or lifelong immunity • Protection begins to wane 3-5 years after vaccination • No discernable immunity after 12 years

  14. THANK YOU!! Noon conference: Residents as Teachers (Dr. English) Students off!!

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