PERTUSSIS (Whooping cough)
PERTUSSIS (Whooping cough) GENERAL CONSIDERATION
The disease persists in unimmunized populations of the world as a highly contagious and potentially fatal disease of infants. It is caused by Bordetella pertussis (Hemophilus pertussis), first described by Bordet and Gengou in 1906. The illness is characterized by a catarrhal period of nonspecific respiratory symptoms that progresses to a stage of paroxysmal cough accompanied by the typical inspiratory whoop and vomiting. It may be complicated by potentially serious involvement of lower respiratory tract and the CNS. Protection from severe clinical infection usually follow an attack of pertussis.
In traditional Chinese medicine, the disease is called "Dun Ke," "Ji ke" and "Lu Ci Ke," which all mean an infectious disease frequently seen in children, caused by seasonal pathogens with obstruction of the air passages by putrid phlegm, and
characterized clinically by chronic paroxysmal spasmodic coughs.
It is customary to divide the clinical course of whooping cough into three stages--catarrhal, paroxysmal and convalescent.
The catarrhal stage lasts for about I to 2 weeks. It begins with the symptoms of an upper respiratory tract infection or common cold, such as coryza, sneezing, lacrimation, cough, and low-grade fever. The child may appear listless and irritable. In the absence of a history of contact, whooping cough is not suspected. Sometimes the only manifestation is a dry hacking cough that excites little attention. After about a week the cough, instead of improving, gradually becomes more severe. It is likely to be especially troublesome at night and it begins to occur in paroxysms.
The paroxysmal stage lasts, as a rule, 4 to 6 weeks, with outside limits of 1 to 10 weeks. The cough now comes in explosive bursts. A series of five to ten or more short, rapid coughs is given on one expiration and is followed by a sudden inspiration associated with a characteristic high-pitched crowing sound or whoop. During the attack, the child's face becomes red or cyanotic, the eyes bulge, the tongue protrudes, and the whole expression is anxious or utterly miserable. A number of paroxysms may be grouped together until, with the last one, the child succeeds in dislodging the mucous plug and brings up thick, tenacious material. Vomiting frequently follows the attack. Then the child often appears listless, dazed, or out of touch for a few minutes. The patient is likely to sweat profusely and to show facial edema, particularly around the eyes.
The number of paroxysmal attacks varies from four or five daily in mild cases to as many as 40 in more severe forms. The attacks are likely to occur more frequently at night than during the day time and more frequent in a stuffy room than in one well aired or outdoors. They may be precipitated by eating or drinking, by pressure on the trachea, by physical exertion, or by suggestion. Attacks tend to diminish during periods when the child's attention is concentrated on toys, puzzles, or books. Between attacks the patient is usually comfortable and does not seem ill. In some instances the typical whoop is not heard in spite of the severity and frequency of paroxysms. This is particularly true of infants under 6 months of age. In older persons and in those partially protected by vaccine, a typical mild attacks may occur in which only one or two whoops or none at all occur.
During the first 1 or 2 weeks of the paroxysmal stage, the attacks increase in severity and frequency. They remain at about the same level for a variable period, usually 1 to 3 weeks, and then gradually decline until the whooping and vomiting stop altogether.
The convalescent stage is marked by cessation of whooping and vomiting. The
number and severity of paroxysms decrease gradually. The cough usually lingers for
a while, but its character is that of ordinary tracheitis or bronchitis; it fades away in about 2 or 3 weeks, with subsequent respiratory tract infections. Some patients will develop recurrent paroxysmal coughing attacks, complete with whoop and vomiting.These episodes may occur repeatedly for months or even for 1 or 2 years.
Having once watched a typical paroxysmal attack and heard the whoop, the physician has little trouble in recognizing subsequent cases. The bursts of short, rapid coughs on one expiration followed by the high-pitched inspiratory crow and the hallmarks of no other disease. Even in the absence of the typical whoop, as in infants, the clinical diagnosis is strongly suggested by the paroxysmal nature of the cough. The red or cyanotic appearance and the associated vomiting.
During the catarrhal stage it is usually impossible to differentiate pertussis on clinical grounds from the common cold, bronchitis, or acute respiratory tract disease caused by various agents. A history of contact with a known case or a cough that becomes aggravated after a week should cause suspicion. It is important at this time to attempt to establish the diagnosis by isolation of B. pertussis from the nasopharynx.
The application of the fluorescent antibody technique to the diagnosis of pertussis offers a rapid method of identifying the organism after it has been isolated. However, it is not sufficiently specific to be used for examination of mucus or organisms from the throat.
The white blood cell count may contribute to the diagnosis. High counts with a predominance of lymphocytes are characteristic of whooping cough. At the end of the catarrhal phase, white blood cell counts of 20,000 to 30,000 per cubic millimeter, with 60 or more lymphocytes, are suggestive of the disease.
I. Treatment in Western medicine.
1. Specific treatment
Available evidence suggests that pertu