Pertussis Infection in the United States: Role for Vaccination of Adolescents and Adults

Dennis A. Brooks, MD; Richard Clover, MD

Disclosures

J Am Board Fam Med. 2006;19(6):603-611. 

In This Article

Clinical Manifestations and Complications of Infection

Pertussis symptoms are nonspecific in nature, making the clinical diagnosis challenging. The type and severity of symptoms that develop are highly variable, as is the time frame over which they appear and resolve. Adolescents and adults, as well as those partially protected by pertussis vaccine, frequently have mild clinical disease (or even asymptomatic disease) that goes undiagnosed. Although illness may be milder in adolescents and adults, they are a reservoir of infection and may transmit whooping cough to unimmunized or partially immunized infants. Of great concern, health care providers often do not recognize the varied clinical presentations and do not consider a pertussis diagnosis in patients with chronic cough.[17] Furthermore, management of pertussis is complicated by the fact that infected persons are most contagious early in their illness, before they become symptomatic.

Despite significant interpatient variability, generalizations can be made about the clinical course of illness ( Table 2 ).[5,24] Pertussis infection develops in four sequential stages, beginning with an incubation period during which infected individuals are asymptomatic followed by three stages of symptomatic illness. The incubation period of pertussis infection commonly lasts for 7 to 10 days, but can be as short as 4 days or as long as 21 days. The first stage in which symptoms can be observed is the catarrhal stage. This stage, which typically lasts 1 to 2 weeks, is characterized by the insidious onset of coryza, sneezing, low-grade fever, and a mild, occasional, nonspecific cough that gradually becomes more severe. In young infants, this stage is often characterized by excessive sneezing or "throat clearing."

During the next stage, the paroxysmal stage, many pertussis patients have bursts, or paroxysms, of numerous, rapid coughs, apparently due to impaired mucociliary clearance. At the end of the paroxysm, a long inspiratory effort is oftentimes associated with a high-pitched whoop. Post-tussive vomiting and cyanosis can also occur. The paroxysmal attacks increase in frequency during the first 1 to 2 weeks, remain at the same level for 2 to 3 weeks, and then gradually decrease.

During the convalescent stage, which lasts for weeks to months, recovery is gradual, with cough becoming less paroxysmal and then disappearing.

The symptomatology of infants during the paroxysmal stage of infection is different from that in adolescents and adults. Although very young infants do experience paroxysms of coughing, they often do not "whoop." Although the absent whoop in adolescents and adults is usually associated with milder disease, the whoop may be absent in infants because they lack sufficient musculature in the chest wall to take the deep inhalation that creates the whooping sound. The whoop may appear later in the disease as infants gain in size and strength. Infants may also exhibit clinical symptoms such as gagging, gasping, or eye bulging. Occasionally, they may also present with bradycardia or cyanosis. Pertussis is often ignored in the differential diagnosis of cough illness in young infants due to the absence of a "whoop" and the frequency of concomitant respiratory infections.

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