Do you know these atypical manifestations of whooping cough?
"Cough! Cough! Cough!"-Winter is the season of high influenza incidence, and it is also the season where various microorganisms take advantage of their weaknesses. Among the many diseases whose main manifestation is cough, whooping cough is the most troublesome one.
At the 25th National Pediatric Academic Conference of the Chinese Medical Association this year, Professor Yao Kaihu from the Beijing Children’s Hospital of the Capital Medical University of the National Children’s Medical Center explained in detail the prevalence of pertussis in children and the choice of drugs. We will follow Professor Yao’s Wonderful speech, let's learn together!
What is whooping cough?
Pertussis is generally caused by Bordetella pertussis (abbreviated as B. pertussis) infection. Bordetella bronchiseptica and Bordetella parapertussis can also be caused by the same genus. A typical patient with
has a full course of 6 to 8 weeks. The clinical course can be divided into three stages:
catarrhal stage
from the onset of onset to the appearance of spasm, usually 1 to 2 weeks. The initial symptoms are similar to a cold. In addition to coughing, there may be runny nose, sneezing, low-grade fever, or only dry cough. When other symptoms gradually disappeared, the coughing worsened.
The spasm period
is generally 2 to 4 weeks or longer (a few days to more than 2 months). Paroxysmal and spastic cough are the characteristics of this period. Coughing occurs in clusters during the attack, with more than ten or dozens of coughing, until coughing up sputum or spitting out stomach contents, followed by a deep inhalation, making a cock-like inhalation roar. When coughing is severe, there may be incontinence of urination and urination, clenching fists and elbows, round eyes, red face, red ears, tears and tears, head leaning forward, mouth stretched out, cyanosis, etc., and the expression is extremely painful.
is mild several times a day, severe cases dozens of times a day, more often at night; running, eating, cold, smoking, crying, etc. can be induced; generally there is no obvious warning before the attack.
The recovery period of
is usually 1 to 2 weeks, the number of coughing attacks is reduced, the degree is reduced, and paroxysmal cramps no longer appear. However, if you encounter irritation such as heavy smoke, or have respiratory infections, paroxysmal coughing can be repeated. The prevalence of
has dropped and has risen, and
should be alert to the resurgence of whooping cough!
Before the advent of whooping cough vaccine, whooping cough was an epidemic infectious disease, there was an epidemic peak every three years, mainly infections of infants and young children, and the mortality rate was very high. Fortunately, with the popularity of vaccination, the prevalence of whooping cough has dropped significantly.
But in recent years, the prevalence of whooping cough has started to increase again.
Picture taken from Professor Yao Kaihu PPz
In fact, vaccination alone for whooping cough cannot completely block the spread of the pathogen in the population.
From an epidemiological perspective, whooping cough should have its epidemic law. However, the data we reported cannot fully reflect the true prevalence of whooping cough in my country, and it completely underestimates the prevalence of whooping cough in my country.
Picture taken from Professor Yao Kaihu PPz
From the data in the above table, we see that nearly 80% of the cases submitted for inspection are infants, and nearly 80% of the positive cases are infants.
Is pertussis only spread in babies? What caused the under-reporting of pertussis cases in my country? It is because our clinicians have insufficient knowledge and diagnosis of whooping cough!
Multiple factors affect the diagnosis of whooping cough:
human factors
1. Patients do not seek treatment (mild and atypical symptoms);
2. Doctors have insufficient knowledge of whooping cough, leading to misdiagnosis (especially adolescents and adults);
3. Doctors cannot diagnose and report for various reasons;
4. Reporting obstacles in management;
5. Antibiotic abuse may cause the clinical symptoms of whooping cough to be masked.
objective factors
1. Blood routine and CRP are not specific;
2. Pertussis pathogen culture is more difficult;
3. PCR requirements are relatively high, and it is not easy to carry out basic hospitals;
4. The level of antibodies is difficult to distinguish natural infection and vaccine factors ;Z1z
5. The most important thing is that most hospitals (disease control) have not carried out any detection methods for whooping cough, and they have insufficient understanding of the clinical manifestations of whooping cough, and effectively guide the diagnosis of clinical practice.The break standard is missing.
Re-understand whooping cough
from "whooping cough" to "a cough disease"
1. Clinical manifestations are atypical:
adolescents and adults whooping cough is often atypical.
German adults: more than 2/3 have Paroxysmal cough (paroxysmal cough), 1/3 have cock-like echo.
Adults in North America: Coughing may be severe and long lasting, but Paroxysmal cough is rare and echoes are not common.
coughing with vomiting suggests that long-term coughing in adults may be pertussis.
Other symptoms suggestive of whooping cough include: night cough, sweating episodes, long-term cough exposure. Z1z
2, the three-stage disease course is atypical:
catarrhal period, cramping cough period, recovery period three-stage symptoms are shortened or no obvious stage, but only a long-term cough lasting more than two weeks.
3. Natural infection of whooping cough cannot obtain lifelong immunity, and can be infected again.
4, whooping cough immunization can not obtain lifelong immunity, and may still be infected.
5, the clinical manifestations of post-immunization or re-infection cases can be asymptomatic, mild short-term cough, persistent cough (>2 weeks), chronic cough, and typical cough.
The past and current diagnosis of whooping cough in China actually only recognizes a part of typical whooping cough. Past evaluations of vaccines have shown the impact of vaccination on typical whooping cough, while our knowledge of atypical whooping cough is limited.
So, how should we diagnose whooping cough?
1. Laboratory diagnosis is a guarantee for whooping cough. has no laboratory, atypical pertussis will be misdiagnosed and missed a lot!
table. Laboratory diagnostic methods
According to Professor Yao Kaihu’s PPT, after collecting
specimens, we need to perform strain identification, agglutination experiments, pathogenic nucleic acid sequence detection and serological determination to make a diagnosis. Among them, serological testing is of special significance for diagnosing whooping cough-it is the only effective method for diagnosis of whooping cough patients who go to the doctor late.
The timing and change of the known test indicators often come from the study of the first infection of whooping cough alone, and those who are vaccinated or who are re-infected with whooping cough may be different. Bacterial isolation and culture should be encouraged, because it has 100% specificity in the diagnosis of whooping cough, which helps to eliminate the doubt that clinicians may initially diagnose whooping cough. You should not rely on one method to diagnose whooping cough, but should use multiple methods to diagnose whooping cough at the same time.
2, epidemiology is an important clue to the suspected diagnosis of whooping cough: the contact history of patients with pertussis/(long-term) cough.
3, pertussis is a disease that can be clearly diagnosed. When diagnosing diseases such as (class) pertussis syndrome, pertussis should be excluded first.
excludes whooping cough also requires a unified standard. When establishing a pertussis laboratory test method, we must pay attention to the value of its positive diagnosis of whooping cough, and the value of its negative exclusion diagnosis, because in the clinical management of pertussis, reliable exclusion diagnosis is sometimes more urgent.
How to treat children with pertussis
?
antibacterial treatment:
▎ macrolide antibiotic
erythromycin: 40~50mg/kg/d, q6h, use 14 days or 7~10 days.
Azithromycin: 10mg/kg on day 1, 5mg/kg, or 10mg/kg*5 days on day 2~5.
Clarithromycin: 15~20mg/kg per day, divided into two times for 7 days.
▎ still does not have a uniform standard for the detection method and result determination of B. pertussis antibiotic sensitivity test.
▎ erythromycin: literature reports that the diameter of the antibacterial ring obtained by the disc diffusion method is more than 42mm, which can be considered as erythromycin sensitive. Whether drug-resistant bacteria also need the assistance of laboratory testing!
can choose: TMP/SMX, 8mg/kg/d, divided into two, used for 10 days.
prevention, the best treatment plan!
pertussis is a vaccine preventable disease, prevention is always a very important measure, but it must be remembered that immunization is only a very important way to ensure that these vaccinated children will not be severely ill and will not cause death. Important measures.
Summary
■ Epidemiological and clinical manifestations:
1, the current epidemic of whooping cough in my country is seriously underestimated;
2, natural infection of whooping cough and vaccine immunity can not produce life-long immunity;
3, the current domestic immunization program is not enough to protect the year Older children and adults, atypical cases of older children and adults are the source of infection for infants whooping cough;
4, whooping cough has various clinical manifestations, and it is not fully clear.
Diagnosis of whooping cough:
1, the current diagnostic criteria for whooping cough does not take into account clinical needs and need to be improved;
2, whooping cough is a disease that can be clearly diagnosed. When diagnosing (like) pertussis syndrome and other diseases, pertussis should be excluded first;
3, The diagnosis of pertussis is inseparable from laboratory diagnosis.
Treatment and prevention of whooping cough:
1, domestic bacillus pertussis is highly resistant to macrolides such as erythromycin;
2, drugs for drug-resistant infections: sulfonamides, quinolones? β-lactams?
3. Judgment of the efficacy of antibacterial treatment of pertussis pathogens: bacterial culture (depending on the laboratory);
4, clinical isolates virulence antigens are generally the same as the vaccine strains except for the ptxA genotypes and vaccine strains. Immunization and vaccination The effectiveness of its vaccination strategy for individual and group protection is worthy of attention;
5. Domestic immunization strategies need to be improved.
This article first published: Medical Pediatrics Channel
Report Expert: National Children's Medical Center, Capital Medical University Beijing Children's Hospital Professor Yao Kaihu
This article is organized by: Medical NCCPS 2020 Report Group-Chen Peng
Chief Editor: Li Xiaorong
