eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Pertussis: Differential Diagnoses & Workup

Author: Joseph J Bocka, MD, Director of Shelby Emergency Department, Attending Emergency Physician at Mansfield Hospital, Med Central Health System (Mansfield and Shelby, Ohio); Emergency Medical Service Medical Director for several services
Contributor Information and Disclosures

Updated: May 26, 2009

Differential Diagnoses

Asthma
Pediatrics, Gastroenteritis
Bronchitis
Pediatrics, Intussusception
Chronic Obstructive Pulmonary Disease and Emphysema
Pediatrics, Tachycardia
Encephalitis
Pneumonia, Aspiration
Foreign Bodies, Trachea
Pneumonia, Bacterial
Gastroenteritis
Pneumonia, Mycoplasma
Pediatrics, Bronchiolitis
Pneumonia, Viral
Pediatrics, Croup or Laryngotracheobronchitis
Tuberculosis
Pediatrics, Dehydration
Pediatrics, Febrile Seizures
Pediatrics, Fever

Other Problems to Be Considered

Common cold
Adenoviral syndromes
Influenza
Cystic fibrosis
Interstitial pneumonitis

Workup

Laboratory Studies

  • Blood work
    • Lymphocytosis is often profound (>70% of the total WBC count), especially in children.
    • The WBC count often increases to 20-40,000 or even 100,000 cells/mm2.
    • In adults, especially those that had been vaccinated, lymphocytosis is rare.
  • Cultures
    • A definitive culture diagnosis is not always possible.
    • Results of blood culture are uniformly negative because B pertussis grows solely in the respiratory epithelium.
    • An immediately plated, deep, culture of a nasopharyngeal swab sample grown in Regan-Lowe charcoal agar or fresh Bordet-Gengou is considered the criterion standard for those who present within the first 3 weeks of their cough. The results are positive in <50% (perhaps 15-40%) of cases, and results become available too late (about 1 week) to be clinically useful. The CDC recommends this test to characterize the illness.
  • Direct fluorescent antibody (DFA) studies
    • DFA studies are performed by using a nasopharyngeal sample.
    • Although the results can be available within minutes, its use is not recommended because of both low sensitivity and low specificity.
    • Results are positive in 40-80% of patients and are now used to confirm most cases.
    • Specimens should be obtained within the first 3 weeks of the disease (ie, in incubation, catarrhal, or early paroxysmal stages) or the sensitivity and specificity decrease.
  • Polymerase chain reaction (PCR) testing to detect DNA
    • PCR testing may reveal <10 organisms per swab sample.
    • Its sensitivity may be greater than that of culturing.
    • False-positive results have been a problem, with some reports of more than 50%. Although this or a positive culture is the case definition for reporting pertussis to the CDC or WHO, some are now recommending ELISA confirmation before declaring an epidemic.   
  • Enzyme-linked immunosorbent assay (ELISA) is also useful. Many now consider serologic testing with ELISA to be the criterion standard.

Imaging Studies

  • Chest radiography may show focal atelectasis and/or peribronchial cuffing.
  • The CDC recommends both culture and PCR tests if a patient has a cough lasting longer than 3 weeks.

More on Pediatrics, Pertussis

Overview: Pediatrics, Pertussis
Differential Diagnoses & Workup: Pediatrics, Pertussis
Treatment & Medication: Pediatrics, Pertussis
Follow-up: Pediatrics, Pertussis
References
Further Reading
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References

  1. Centers for Disease Control and Prevention. Outbreaks of respiratory illness mistakenly attributed to pertussis--New Hampshire, Massachusetts, and Tennessee, 2004-2006. MMWR Morb Mortal Wkly Rep. Aug 24 2007;56(33):837-42. [Medline]. [Full Text].

  2. Glanz JM, McClure DL, Magid DJ, Daley MF, France EK, Salmon DA, et al. Parental refusal of pertussis vaccination is associated with an increased risk of pertussis infection in children. Pediatrics. June 2009;123(6):1446-51. [Full Text].

  3. Centers for Disease Control and Prevention. Immunization Schedules. Available at http://www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed March 31, 2009.

  4. [Guideline] Recommended childhood and adolescent immunization schedules--United States, 2009. Pediatrics. Jan 2009;123(1):189-90. [Medline].

  5. [Guideline] Centers for Disease Control and Prevention. Pertussis vaccination: use of acellular pertussis vaccines among infants and young children. Use of diphtheria toxoid-tetanus toxoid-acellular pertussis vaccine as a five-dose series. (Addendum). 1997 guideline with 2000-2003 supplements. [Full Text].

  6. [Guideline] American Academy of Pediatrics Commitee on Infectious Diseases. Prevention of pertussis among adolescents: recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine. Pediatrics. Mar 2006;117(3):965-78. [Medline].

  7. Aoyama T, Sunakawa K, Iwata S, et al. Efficacy of short-term treatment of pertussis with clarithromycin and azithromycin. J Pediatr. Nov 1996;129(5):761-4. [Medline].

  8. Bass JW, Stephenson SR. The return of pertussis. Pediatr Infect Dis J. Feb 1987;6(2):141-4. [Medline].

  9. Centers for Disease Control and Prevention. Recommended Adult Immunization Schedule-United States, October 2007-September 2008. MMWR Morb Mortal Wkly Rep. Oct 19 2007;56(41):Q1-Q4. [Full Text].

  10. Centers for Disease Control and Prevention. Recommended Immunization Schedules for Persons Aged 0--18 Years ---United States, 2008. MMWR. 2007;56(51&52):Q1-Q4.

  11. Centers for Disease Control and Prevention. Vaccine preventable deaths and the Global Immunization Vision and Strategy, 2006-2015. MMWR Morb Mortal Wkly Rep. May 12 2006;55(18):511-5. [Medline]. [Full Text].

  12. Geier DA, Geier MR. An evaluation of serious neurological disorders following immunization: a comparison of whole-cell pertussis and acellular pertussis vaccines. Brain Dev. Aug 2004;26(5):296-300. [Medline].

  13. He Q, Viljanen MK, Arvilommi H, et al. Whooping cough caused by Bordetella pertussis and Bordetella parapertussis in an immunized population. JAMA. Aug 19 1998;280(7):635-7. [Medline].

  14. Nennig ME, Shinefield HR, Edwards KM, et al. Prevalence and incidence of adult pertussis in an urban population. JAMA. Jun 5 1996;275(21):1672-4. [Medline].

  15. Roush SW, Murphy TV,. Historical comparisons of morbidity and mortality for vaccine-preventable diseases in the United States. JAMA. Nov 14 2007;298(18):2155-63. [Medline].

  16. Tindberg Y, Blennow M, Granstrom M. A ten year follow-up after immunization with a two component acellular pertussis vaccine. Pediatr Infect Dis J. Apr 1999;18(4):361-5. [Medline].

  17. Ward JI, Cherry JD, Chang SJ, Partridge S, Lee H, Treanor J. Efficacy of an acellular pertussis vaccine among adolescents and adults. N Engl J Med. Oct 13 2005;353(15):1555-63. [Medline].

  18. Wright SW, Edwards KM, Decker MD, Lamberth MM. Pertussis seroprevalence in emergency department staff. Ann Emerg Med. Sep 1994;24(3):413-7. [Medline].

  19. Wright SW, Edwards KM, Decker MD, Zeldin MH. Pertussis infection in adults with persistent cough. JAMA. Apr 5 1995;273(13):1044-6. [Medline].

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Keywords

whooping cough, pertussis, Bordetella pertussis, B pertussis, pertussis vaccination, acellular vaccination, whole-cell vaccination, protracted cough, vaccine-preventable disease, cough in infants, whole-cell vaccine, acellular vaccine, DTaP, Tdap, Td booster, immunization schedule, vaccines

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Contributor Information and Disclosures

Author

Joseph J Bocka, MD, Director of Shelby Emergency Department, Attending Emergency Physician at Mansfield Hospital, Med Central Health System (Mansfield and Shelby, Ohio); Emergency Medical Service Medical Director for several services
Joseph J Bocka, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Association of EMS Physicians, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Garry Wilkes, MBBS, FACEM, Director of Emergency Medicine, Bunbury Health Service, Western Australia Country Health Service; Adjunct Associate Professor, School of Exercise, Biomedical and Health Sciences, Faculty of Computing, Health and Science, Edith Cowan University; Medical Director, St John Ambulance Service
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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