17/08/1443

Pertussis (whooping
cough)
it is caused by Bordetella
pertussis which is
fastidious, gram-negative
coccobacilli. Bordetella
parapertussis is an
occasional cause of
sporadic pertussis .

1
17/08/1443

EPIDEMIOLOGY:

- It is extremely contagious, with attack rates 100% in close

contacts.

- After intense exposure , the rate of subclinical infection is 80%

in fully immunized or previously infected individuals.

- Neither natural disease nor vaccination provides complete or

lifelong immunity against reinfection or disease.
- Mothers provide little protection to young infants.

Transmission is by droplets released during intense

coughing especially in the catarrhal stage.

2
17/08/1443

CLINICAL MANIFESTATIONS:
Incubation period 3–12 days. Pertussis divided into 3
stages:
1- The catarrhal stage (1–2 wk) :begins with congestion
and rhinorrhea, low-grade fever, sneezing, lacrimation,
conjunctivitis, & mild dry cough .

2- paroxysmal stage(2-6wk.): The cough begins as a dry,

intermittent, irritative and progress into the paroxysms.

During attack of paroxysm, chin

and chest held forward, tongue
protruding maximally, face
purple, until coughing ceases
and a loud whoop(forcefull
inspiratory gasp) follows.

This whoop not apparent in

infant < 3 mo. of age & adults.

3
17/08/1443

4
17/08/1443

Infants <3 mo of age do not

showing classical stages.

The catarrhal phase lasts only

a few days. After that, young
infant begins to choke, gasp,
with face reddened.

Cough may not be prominent &

Whoop infrequently occurs.

Cyanosis can follow a coughing paroxysm, or apnea can

occur without a cough. Apnea may be the only symptom .

Immunized children have foreshortening of all stages of

pertussis.

5
17/08/1443

3- Convalescent stage (≥2 wk) : the number, severity, and

duration of episodes diminish. Chronic cough may persist for
several months.

- Findings on physical examination are uninformative.

Conjunctival hemorrhages and petechiae on the upper body are
common.

DIAGNOSIS :
1- typical clinical presentation.
2- Leukocytosis (15,000–100,000 cells/mm3) with absolute
lymphocytosis .

2- Chest x-ray: showing perihilar infiltrate or edema and

atelectasis. Pneumothorax & pneumomediastinum can be
seen.

3- Isolation of B. pertussis in culture of specimen obtained by

deep nasopharyngeal aspiration .

4- polymerase chain reaction.

5- serologic tests for detection of antibody to B. pertussis

antigen in acute & convalescent samples.

6
17/08/1443

COMPLICATIONS :
1- Apnea especially in infants < 3mo. of age .

2- Secondary bacterial infections (such as otitis media and

pneumonia) .

3- Bronchiectasis .

4- conjunctival and scleral hemorrhages, epistaxis,

hemorrhage in the central nervous system (CNS) and
retina result from increased intrathoracic and intra-
abdominal pressure during coughing .

5- pneumothorax and subcutaneous emphysema .

6- umbilical and inguinal hernias .

7- Seizures due to hypoxemia, intracranial hemorrhage or

hyponatremia from excessive secretion of antidiuretic hormone
during pneumonia can occur.

7
17/08/1443

TREATMENT :
Indications for hospitalisation :

*infants < 3mo. of age are admitted to hospital almost without

exception.

*Those between 3–6 mo if paroxysms are severe

*Those of any age if significant complications occur.

1-Supportive care:
- avoid provoking factors for cough like smoke, excessive -
stimulation .
- Good hydration, adequate nutrition & avoid large volume -
feeding .
- For excessive secretion, frequent suction to clean airway
& prevent aspiration .

2- Antibiotics:
- Azithromycin :it is drug of choice in neonates,
10mg/kg/day for 5days.

8
17/08/1443

Alternatives drugs are:-

- Erythromycin 40 -50mg/kg/day in 4 divided doses for 14 -
days (associated with hypertrophic pyloric stenosis in neonates)
.
Or Clarithromycin, Trimethoprim-sulphamethoxazole (TMP-
SMZ) .

3- respiratory isolation of patient immediately & until 5days after

initiation of macrolide therapy .

4- macrolide agents should be given to all close & household

contacts regardless of age, history of immunization or
symptoms.

PREVENTION :
DPT vaccine.

Varicella (chickenpox)
Varicella-Zoster Virus(VZV)
It is double-stranded DNA human herpesvirus.
It causes primary infection which is varicella (chickenpox).
This infection result in lifelong latent infection of sensory
ganglion neurons.

Reactivation of this latent infection causes herpes zoster

(shingles).

9
17/08/1443

EPIDEMIOLOGY :
- Patients with varicella are contagious from 24 to 48 hr
before the rash appears and until vesicles are crusted,
usually 3–7 days after onset of rash.
Transmission by respiratory secretions and the fluid of skin
lesions either by airborne spread or through direct contact.

Clinical manifestations
-Incubation period 10 to 21 days.
- Fever, malaise, anorexia, headache, and mild abdominal
pain occur 24–48 hr before the rash appears. Fever persist
during the 1st 2–4 days after the onset of the rash.

- Varicellarash appear first on the scalp, face, or trunk. Initially

consists of intensely pruritic erythematous macules that evolve
through the papular stage to form clear, fluid-filled vesicles.
Clouding of the lesions begin in 24–48 hr.

The distribution of the rash is centripetal.

10
17/08/1443

11
17/08/1443

Neonatal Chickenpox :
Infants whose mothers develop varicella in the period from 5
days before to 2 days after delivery are at high risk for severe
varicella, because the mother has not yet developed a
significant antibody response. Those newborn given human V-
Z Ig & if develop disease give acyclovir .

If the mother develops varicella more than 5 days prior to

delivery, infection is attenuated due to transmission of maternal
antibody across the placenta.

12
17/08/1443

Congenital Varicella Syndrome (CVS):

When pregnant women develop chickenpox early in
pregnancy(1st 20 wk of pregnancy) , 2% of fetuses demonstrate
CVS .
Stigmata of CVS:

- Cicatrix (a zigzag scarring, in a dermatomal distribution), &

hypopigmentation due to damage to sensory nerves.
- Microphthalmia, Cataracts ,Chorioretinitis &optic atrophy.

- Microcephaly, Hydrocephaly, & brain Calcifications .

- Hypoplasia of an extremity, Motor and sensory deficits ,,
Anal/urinary sphincter dysfunction.

Diagnosis of CVS :
1- History of gestational chickenpox with stigmata in the fetus .
2- PCR to detected viral DNA in tissue samples .
3- VZV IgM antibody detected in the cord blood sample.
TREATMENT: No specific treatment for CVS.

13
17/08/1443

14
17/08/1443

15
17/08/1443

DIAGNOSIS :
1- Clinically
2- Leukopenia with relative lymphocytosis .
3- Direct fluorescence assay to identify the virus from the
cutaneous vesicular lesions .
4- PCR .
5- 4-folds rise in VZV-IgG antibodies .

COMPLICATIONS :
1- Secondary bacterial infections : include superficial impetigo,
cellulitis, and subcutaneous abscesses .

2- Encephalitis and Cerebellar Ataxia.

3- Reye syndrome: can associated with varicella especially if

aspirin use as antipyretic .

16
17/08/1443

4- Transverse mylitis & Gullian barre syndrome.

5-Pneumonia.
6- others rare complications: hepatitis, nephrotic syndrome,
hemolytic-uremic syndrome, myocarditis, pancreatitis,
thrombocytopenia.

TREATMENT :
1- Aspirin should not be used as antipyretic in varicella .
2- Calamine lotion for soothing pruritis, or use antihistamine .

3- Acyclovir : indicated for sever disease & in

immunocompromised patients, I.V 10mg/kg/dose every
8hr.
Oral Acyclovir used for herpes zoster in children .

PREVENTION :
1-Varicella vaccine .

2- Postexposure Prophylaxis :
varicella-zoster immune globulin (VZIG) given within
96hr. of exposure, indicated in :

17
17/08/1443

1- immunocompromised patients .

2- pregnant woman .

3- Newborns whose mothers develop varicella 5 days before to

2 days after delivery .

4- premature infants <28 wk of gestation .

5- high-risk patient in close contacts with patient have herpes

zoster .

Thank you

18