• Whooping cough symptoms in adults and children

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    Pertussis is an acute infectious disease with an airborne droplet mechanism characterized by a cyclic course and a long-lasting seizure cough and is an extremely contagious, potentially serious bacterial infection of the respiratory tract. The development of symptoms occurs in three stages, each of which lasts several weeks. Any person can get whooping cough , but he is the most dangerous for children when a violent cough interferes with breathing. Pneumonia, convulsions and encephalopathy can be serious complications in young children. Pertussis in older children and adults leads to mild symptoms, for example, to stuffy nose and cough. The vaccine does not provide full immunity, but it protects children when they are most at risk of contracting infection. How to treat this disease with folk remedies. Aetiology of pertussis and paracottus. Pathogens of pertussis and paracutosis - Bordetella pertussis and Bordetella parapertussis, belonging to the genus Bordetella, small coccobacillary, asporogenous gram-negative chemo-organotrophic immobile aerobic bacteria. They multiply on media rich in blood. Species differ in the following features: B. pertussis has a gentle capsule. B. parapertussis does not have a capsule, in contrast to B. pertussis utilizes citrates, grows on MPA, MPB, forming a soluble pigment, produces urease, does not restore nitrates.

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    Bordetella are characterized by pronounced variability of properties, antigenically also heterogeneous. As a part of bacteria, there is a rhodospecific thermostable antigen, capsular agglutinogen, a set of 14 generic and species-specific agglutinogens named factor and designated 3, 4, 5, 6, for paracottus - 8, 9, 10.

    B. pertussis possesses histamine-sensitizing, leukocytosimulating,dermatomic necrotic, hemagglutinating and hemolytic activity. Pathogenesis of whooping cough is associated with the release of toxic substances:

    Pathogenicity is mediated by enzymes of pathogenicity - coagulase, hyaluronidase, lecithinase, etc.

    Pathogens and pertussis are unstable in the environment, killed by drying, ultraviolet irradiation, disinfectants.

    Macrolides, tetracyclines, levomycetin, aminoglycosides are sensitive to antibiotics. Epidemiology of pertussis. The source of the infection is a sick person. Excretion of the pathogen begins in the last days of the incubation period. In the catarrhal period, pertussis is isolated by almost all patients. With the development of spasmodic cough, the contagiousness of the patient decreases, however, even at week 4, 5-15% of patients continue to be sources of pertussis infection. Under the influence of antibacterial drugs, the release of the organism from the microbe is accelerated.

    A large role as a source of infection is played by patients with erased forms of the disease.

    The treatment of pertussis in healthy children is extremely rare and short-lived.

    Transmission of the pathogen is carried out by an air-drop mechanism. During the cough, droplets of nasopharyngeal mucus of the patient, containing microbes, enter the air. Due to the small resistance of the rod outside the human body and its low volatility, contact with the patient should be sufficiently close and prolonged.

    Suffer from whooping cough, starting from the first month of life, because there is no congenital anticonclusive immunity.

    The highest incidence rates are observed at the age of 3 to 6 years.

    In the past decade there has been an increase in the incidence of whooping cough. The reasons for the periodic increase in the incidence of whooping cough since 1990 are:

    Pathogenesis of whooping cough. Pertussis stick penetrates the upper respiratory tract, where it is attached to the ciliated epithelium, colonizes it. On the site of adhesion and colonization, ciliastasis occurs, hemorrhages develop, necrosis. The most pronounced pathological process in the bronchi, bronchioles, less - in the trachea, larynx, nasopharynx. Muco-purulent exudate closes the lumen of small bronchi, which leads to the formation of atelectasis, emphysema.

    Pertussis stimulates several toxic and virulent substances: filamentous hemagglutinin, pertussis toxin, lipopolysaccharide, thermolabile toxin, tracheal cytotoxin, adenylate cyclase. The most important is pertussis toxin. It causes profound changes in the receptive zones of the cough reflex, leading to prolonged afferent impulses in the region of the cough and respiratory centers. In addition, pertussis toxin itself acts directly on the respiratory center. All of this contributes to the formation of a focus of pathological excitation, the appearance of a characteristic paroxysmal cough, a change in the rhythm of breathing, a decrease in the sensitivity of medullary chemoreceptors to the level of CO2.Violation of the rhythm of breathing, bronchial patency, changes in oxygen utilization in the cellular metabolic cycle( oppression of cytochrome oxidase) lead to the formation of hypoxemic, cytotoxic hypoxia. Changes in intracellular metabolism, cytoxic hypoxia, circulatory disorders contribute to the development of encephalic disorders and the most formidable complication - encephalopathy.

    A significant role in the formation of clinical manifestations of whooping cough is affected by the cardiovascular system, which is based on the pathological effect of pertussis thermolabile toxin, irradiation from the dominant focus of excitation to the vasomotor center. The above leads to vasospasm, increased blood pressure, and vascular permeability.

    Morphological changes in pertussis .Lethal outcomes from whooping cough are currently rarely recorded and are due to the development of severe forms of mixed infections or complications.

    In the larynx, trachea, bronchi of the patient with pertussis, a pronounced serous inflammation is found.

    In the lungs, functional disorders are emphysema, atelectasis, spastic bronchi. Productive inflammation is present in peribronchial, perivascular and interstitial tissues. Inflammatory changes in the lungs are detected against the background of pronounced acute disorders of blood and lymph circulation, it is possible to infiltrate lung interstitial tissue with lymphocytes, neutrophils and eosinophils.

    From the central nervous system revealed hyperemia, edema, stasis and hemorrhage. The signs of myocardial dystrophy are determined in the myocardium.

    Immunity after suffering pertussis. An important role in protecting the human body belongs to the humoral link of immunity. The first line of defense is caused by secretory immunoglobulins "A", which prevent the binding and colonization of pertussis epibodies of the upper respiratory tract by pertussis microbes.

    Prolonged immunity to pertussis is due to specific immunoglobulins A and G.

    In the cellular link of immunity, the leading role belongs to T-lymphocytes and macrophages. An increase in the number of all T-cell populations is observed.

    Clinical manifestations of the catarrhal period of pertussis. Clinic of the catarrhal period of whooping cough is characterized by gradual development and the presence of catarrhal and general infectious syndromes. However, the general infectious syndrome is noted in not more than half of patients and consists of short-term subfebrile body temperature( no more than 3-4 days) and minor malaise. The main symptom of the catarrhal period is cough, which is characterized by a gradual increase in intensity and frequency from day to day. Conducted symptomatic therapy has no effect. At the same time, the data of percussion and auscultatory examination of the lungs do not reveal any changes.

    Other catarrhal phenomena( serous discharge from the nose, hyperemia of the posterior pharyngeal wall) are weak in 1/3 of the patients and are stopped within 3-5 days.

    The catarrhal period lasts for an average of 10-14 days. In patients who are immunized with DPT vaccine, it can be prolonged, and in young children - to shorten.

    Clinic of convulsive period of whooping cough. Convulsive period of whooping cough has bright clinical manifestations. In this period the cough acquires a paroxysmal character. The emergence of a coughing attack, as noted by school-age children, can be preceded by a peculiar aura in the form of perspiration and tickling in the throat, sneezing, general malaise, vague compressive pains in the chest area. The attack of a cough is characterized by the presence of a series of rapidly exhaling coughing thrusts, intermittently interrupted by a whistling inhalation - a reprise. The attack of cough lasts up to 5 minutes and ends with the release of viscous sputum or vomiting, or regurgitation in children of the first year of life. The frequency of occurrence of a characteristic cough varies from 5 to 40-50 attacks per day. Coughing attacks often occur in a dream, can be triggered by feeding, physical activity.

    Appearance of the patient during an attack is characteristic: the face is hyperemic, puffy, tears are released from the eyes, the veins of the face, heads, and necks swell. In the beginning, there appears a perioral, and then a diffuse cyanosis of the face, mucous membranes, and tongue. Language during an attack is extremely protruding, on the bridle a sore is formed. At the time of a bout of coughing, hemorrhages to sclera, nosebleeds, petechiae on the face and upper body may appear.

    Equivalents of paroxysmal coughing can be attacks of spasmodic sneezing, in young children - attacks of syncopal apnea. In older children, during a fit of cough, spasmodic apnea occurs as a result of spasm of the glottis and smooth muscles of the respiratory tract.

    Body temperature in the period of convulsive cough does not increase.

    A study of the respiratory organs reveals a tympanic hue of percussion sound( almost in 90% of patients).Auscultation of the lungs reveals on a background of hard breathing dry and moist large bubbling rales that can completely disappear after a fit of cough and resume after a while.

    Cardiovascular system is almost always included in the pathological process, as evidenced by long-lasting tachycardia, arterial and venous hypertension, an increase in the size of the heart to the right, muffledness and deafness of cardiac tones.

    The defeat of the cardiovascular system, metabolic disorders as a result of hypoxia lead to the development of skin pallor, cyanosis of the lips and acrocyanosis, cold extremities.

    Changes in the nervous system are diverse and are determined, in particular, by the degree of oxygen deficiency and the depth of circulatory disorders.

    The first signs of beginning pertussis encephalopathy are general anxiety, alternating with hypodynamia, sleep disturbance at night and increased daytime sleepiness, increased tendon reflexes, convulsive alertness. Convulsions, impaired consciousness, hemiparesis indicate a more severe lesion of the nervous system.

    Encephalopathy develops mainly in patients with an unfavorable premorbid background( intrauterine lesion of the central nervous system, birth trauma, etc.), when pertussis is combined with viral infections( influenza, adenovirus infection, CMVI, etc.).The duration of the period of convulsive cough varies from 1-1.5 weeks in immunized children, up to 4-6 and even 8 weeks in the unvaccinated.

    Period of convalescence recovery. The duration of the reconvalescence period is 2-3 weeks.

    Cough gradually loses its paroxysmal character. Coughing attacks in this period can be provoked by physical or emotional stress.

    After recovery in children, a tendency to relapse of spasmodic cough persists in the development of acute respiratory diseases.

    Reference diagnostic features of the typical form of whooping cough. The following basic diagnostic features of a typical form of pertussis can be distinguished:

    Atypical forms of whooping cough. For the erased form of whooping cough is characterized by the absence of a consistent succession of periods of illness, attacks of convulsive cough. Cough is dry, obtrusive, mainly at night. Occasionally there are single typical attacks of coughing when stratifying intercurrent diseases. The condition of the patients remains satisfactory, sometimes the paleness of the face and the small pastosity of the eyelids are noted. With physical examination of the lungs, emphysema is revealed. Body temperature rarely rises. The duration of cough varies from 7 to 50 days. Hematologic changes are insignificant.

    Subclinical form is characterized by the excretion of the pathogen, the increase in the titre of anti-pertussis antibodies in the patient's blood and the absence of characteristic clinical symptoms.

    Bacteriosis is observed in no more than 2% of children, mostly of school age, vaccinated against pertussis. Within two weeks, the body clears the pertussis.

    Criteria for severity of whooping cough. There are three forms of severity of whooping cough: light, medium heavy, heavy.

    To assess the severity of the infectious process, it is necessary to take into account:

    When assessing the severity of whooping cough, the age of the baby and its premorbid status should be taken into account.

    Clinical manifestations of mild pertussis. In patients with mild pertussis, the general condition is practically unaffected. The number of cough attacks per day is no more than 10-15.Occasionally, a fit of coughing ends with vomiting. Some patients have a mild, rapid perioral cyanosis. Hemorrhagic syndrome is extremely rare. A more permanent symptom is the swelling of the face, eyelids. When examining the lungs, signs of emphysema are found.

    The duration of the spasmodic period is 4-5 weeks.

    Clinic of a moderate form of whooping cough. For the moderate-severe type of whooping cough, the general condition of patients is characterized. Children are capricious, irritable, reduced appetite. The number of cough attacks per day from 16 to 25-30.Paroxysms are long. Often, a fit of coughing ends with vomiting. His face was pale. Periodic cyanosis is observed not only at the time of an attack of cough, but also outside the attack. Possible hemorrhagic elements. When examining the lungs revealed boxed shade of percussion sound, a single dry and wet wheezing, which disappear after a fit of cough and reappear after a short time.

    The duration of the spasmodic period reaches 5-6 weeks.

    Clinical signs of severe pertussis .The prodromal period of severe pertussis is usually 3-5 days.

    The general condition of the child in the period of spasmodic cough is significantly impaired. Children are listless, adynamic;sleep, appetite. The weight curve is flattened or reduced. Coughing attacks reach 30 or more times a day, accompanied by frequent vomiting. Characteristic disorders of the rhythm of breathing, periods of apnea. Perioral or acrocyanosis persists beyond the onset of coughing. Signs of damage to the cardiovascular system are expressed: hemorrhagic rash, deafness of cardiac tones, widening of the heart boundaries, increase of arterial pressure. Perhaps the development of encephalopathy, manifested in the form of convulsions, impaired consciousness, paresis.

    The duration of the period of spasmodic cough can reach 7 weeks.

    Peculiarities of whooping cough in young children. The incubation period is shortened and is 4-7 days. The duration of the prodromal period ranges from 4-5 to 8 days, while the period of spasmodic coughing is prolonged to 50-60 days.

    In infants, moderate and severe forms prevail.

    Cough attacks can be typical, reprises and sticking out of the tongue are marked much less frequently and are not clearly expressed. Possible cough equivalents - sneezing, hiccough, scream. When coughing sputum is allocated a little due to a partial swallowing. In the interictal period, the general condition is disturbed, the appetite is sharply reduced, the weight gain is reduced, and the motor and speech skills acquired earlier may be lost. Skin and subconjunctival hemorrhages are less common, and lesions of the nervous system are more frequent. In newborns, especially premature infants, cough is mild, low-sound. There may be a high incidence of specific complications, including life threatening( apnea, cerebral circulation disorder).Nonspecific complications, mainly pneumonia, develop early.

    Specific hematologic changes are expressed distinctly and persist for a long time. Specific antibodies in the blood are determined at a later date( 4-6th week of the period of convulsive coughing).

    Features of the course of whooping cough at the present stage:

    Features of the course of pertussis infection in vaccinated .The incidence of whooping cough among vaccinated people varies from 1.5 to 43.5% and is 4 to 6 times lower than among ungrafted people.

    The incubation period ranges from 7 to 15 days.

    Mild, atypical erased forms( up to 86%) often develop.

    Reprises and vomiting in the period of spasmodic cough are quite rare, and hemorrhagic and edematic syndromes are not typical at all.

    The disease is characterized by a smooth course, the formation of complications is not frequent.

    Changes in peripheral blood of a pertussis patient. In the catarrhal period of pertussis, there is an increase in the number of leukocytes and lymphocytes in the peripheral blood of the patient. ESR is either reduced or does not differ from the norm. The detected changes persist for 2-3 weeks of the spasmodic cough period. Moreover, the maximum number of leukocytes( up to 40 • 109 / L - 50 • 109 / l) and lymphocytes( up to 85-96%) is recorded in patients with severe pertussis.

    Changes in the respiratory organs during X-ray examination of pertussis patients. X-ray examination of the chest organs of the pertussis patient allows to reveal the horizontal standing of the ribs, increase of the transparency of the pulmonary fields, low standing and flattening of the diaphragm domes, expansion of the pulmonary roots, strengthening of the lung pattern in the form of mesh, cellular and coarse linear strands. Possible lobar or segmental atelectasis.

    Methods for laboratory diagnosis of pertussis and paracottus. The bacteriological method is the basic method of laboratory diagnosis and is aimed at isolating the pathogen. The probability of isolation depends on the timing of the examination, in the first week the frequency of excretory excretion can reach 70%, in the third week - does not exceed 20%.The study is subjected to mucus from the upper respiratory tract, which is taken by the swallowing tampons( dry and moistened with buffered saline).A modern method for diagnosing pertussis is PCR.

    Serological methods are aimed at identifying antibodies to the pathogen. Most often used methods of RNGA and RA with the obligatory study of paired sera. The diagnostic value is the increase in titer 4 times or more. It has also been recommended that an ELISA be performed to detect specific antibodies IgM, IgG.

    Serological methods are only auxiliary, are important for retrospective confirmation of diagnosis in unvaccinated children. Upon contact with pertussis in vaccinated children, the level of antibodies increases, as does the disease, which makes interpretation of the results of the serological examination difficult.

    Differential pertussis in the catarrhal period. In the catarrhal period, the leading syndrome is cough syndrome, therefore the differential diagnosis must first be carried out with acute respiratory-viral infections, chlamydia, mycoplasmosis, legionellosis.

    The main differences in whooping cough in the catarrhal period from ARVI will be the following:

    Differential diagnosis of pertussis in the period of spasmodic cough.

    The leading syndrome of pertussis in the period of spasmodic cough is paroxysmal, spasmodic cough.

    A pertussis-like seizure cough can be observed in a number of diseases: bronchitis and tracheobronchitis, bronchopulmonary form of cystic fibrosis, tuberculous bronchoadenitis, spasmophilia with laryngospasm phenomena, foreign body in the respiratory tract, mediastinal tumors, bronchial asthma, paracottus, pneumonia, lung abscess.

    TB bronhoadenit pertussis in a period of spasmodic cough distinguished:

    mediastinal tumor pertussis distinguish:

    Acute tracheobronchitis pertussis distinguish:

    bronchopulmonary form of cystic fibrosis pertussis distinguish:

    foreign body airway pertussis distinguish:

    Pneumonia pertussis distinguish:

    Classification of whooping cough( Nisevich NI, Uchaikin VF, 1990):

    I. In form:

    II.By the severity of the process:

    III.On the course of the disease:

    IV.By the nature of the complications:

    V. Mixt infection.

    Treatment of

    Treatment of pertussis should be comprehensive considering the age of the patient, the condition of the premorbid background, the severity of the disease.

    Children with severe and complicated forms, children of the first two years of life who are not vaccinated against whooping cough, as well as patients from closed children's groups are subject to hospitalization.

    Etiotropic therapy is prescribed in the catarrhal period and during 2 weeks of the period of spasmodic cough. In later terms, antibacterial agents are prescribed to patients with bacterial complications. Preference should be given to macrolides( sumamed, rovamycin, rulid, erythromycin), cephalosporins 1-2-3-th generation( cefazolin, zeclore), aminopenicillinam( ampicillin, amoxicillin).With a mixed infection( pertussis-herpesvirus), it is necessary to prescribe anti-herpetic drugs( zovirax, etc.) Patients with severe disease are advised to administer antibacterial agents parenterally.

    The course of antibiotic therapy - 5-7 days.

    Pathogenetic treatment:

    Patients are prescribed therapeutic nutrition, children of the first year of life with moderate and severe forms during the height of the disease can be switched to dosed feeding.

    Deadlines for the isolation of pertussis patients. Hospitalization of patients according to clinical and epidemiological indications. Children under 7 years of age are admitted to the team after 25 days from the onset of the disease, and schoolchildren - immediately after the end of the period of acute manifestations of the disease.

    Patients undergo a two-time bacteriological examination and study of peripheral blood.

    Obtaining two negative bacteriological test results is not a basis for reversing the diagnosis in the presence of a clinic and specific changes in peripheral blood.

    Reconvalescent is released from preventive vaccinations for 1 month in uncomplicated course of the disease, for 2 months - with the formation of complications. He is recommended breathing exercises, chest massage, vitamins, plant adaptogens. It is examined by a physician at the CIC in 1 month after discharge from the department or outpatient treatment.

    1. Specific complications:

    2. Complications of inflammatory nature:

    The second group of complications( bronchitis, pneumonia) develops as a result of attachment of a secondary bacterial or viral infection. A special role in the formation of bronchopulmonary complications is attributed to herpesviruses, mycoplasmal, chlamydial infections.

    Consequences of whooping cough:

    Features of the clinical course of mixed pertussis-chlamydial infection:

    After isolation of the patient, children under 7 years of age who were not previously sick with pertussis are suspended from visiting the children's institution for 14 days.

    If it is impossible to isolate the patient, the follow-up time for contact is increased to 25 days.

    Children suffering from pertussis, school children and adults serving children's institutions are not isolated, followed by medical supervision for 14-25 days. During the observation period, the contacts are subject to a two-fold bacteriological examination.

    The children's institution establishes a quarantine for 14 days with compulsory medical supervision and a two-time bacteriological examination of all contacts in a group of children's institutions.

    At school, the volume of activities can be reduced. Bacteriological examination is conducted here only for coughing children.

    Specific prophylaxis is performed with a complex preparation of DTP vaccine( or Tetracoccus 0.5 "Pasteur Merier Connaught", France).

    In connection with the reactogenicity of whole-cell DTP vaccines, the use of the Infanriks vaccine has now begun. Infanrix is ​​a three-component vaccine: diphtheria-tetanus toxoid and acellular pertussis adsorbed. The pertussis component includes pertussis toxin. PHA - filamentous hemagglutinin and pertactin - external membrane protein. On the effectiveness of Infanriks is not inferior to the whole-cell DTP vaccine. With its use it became possible to conduct revaccination of children of older ages.

    The vaccination course consists of 3 intramuscular injections of the drug( 0.5 ml each) at intervals of 1.5 months, beginning at 3 months of age. If it is necessary to increase the intervals, the next vaccination should be carried out as soon as possible, determined by the state of children's health. Revaccination is carried out once at the age of 18 months. Vaccines are stored in the refrigerator at a temperature of 4-8 ° C for 1 year and 6 months. It is strictly forbidden to freeze them, because they completely lose immunogenicity.

    In the 1-2 days after the introduction of the vaccine, fever, soreness, congestion and swelling at the injection site, general malaise are possible. A fever can provoke febrile, short-term cramps.

    In rare cases, there are episodes of piercing screaming, allergic reactions( polymorphic rash, hives, Quincke's edema), exacerbation of chronic diseases. Allergic reactions are more likely to develop at repeated doses of DTP.

    Complications include hyperthermia( more than 40 ° C), dense infiltrates more than 8 cm in diameter, edema, hyperemia at the injection site, anaphylactic shock, a collapoid state, afebrile convulsions with loss of consciousness, very rarely - encephalitis.

    Contraindications to DPT vaccination are:

    Children who have experienced acute illnesses are vaccinated as the clinical manifestations subside. Patients with chronic diseases are vaccinated after reaching a stable remission( at least 4 weeks). The current vaccination scheme for whooping cough DTP vaccine( triple vaccination and one revaccination) creates a high level of immunity, but which decreases to school age. This is what prompted many countries to carry out a second or third revaccination. And this became possible only with the creation and application of the cell-free vaccine Infanriks, which is used in the same way as DTP, but allows additional revaccinations to be carried out at a later age and with less frequency of reactions and complications.