Critical pertussis

Nivetha M^1*, Gayathri Devi V¹, Sonya Mercy Anbu², Ruby³

¹Staff Nurse, MAA Kauvery Hospital, Trichy, Tamil Nadu

² Nursing Educator, MAA Kauvery Hospital, Trichy, Tamil Nadu

³ Deputy Nursing Superintendent, MAA Kauvery Hospital, Trichy, Tamil Nadu

*Correspondence

Introduction

Pertussis, caused by Bordetella Pertussis, is an acute, highly contagious respiratory infection caused by and it is particularly severe in infants and young children, where it can lead to serious complications and death. The disease is transmitted through respiratory droplets during coughing or sneezing and spreads easily in close contact settings. Pertussis, also called whooping cough, is one of the vaccine preventable respiratory infections. It can affect individuals of all age group but particularly it can cause severe illness in infants and young children. A young infant, presented with critical pertussis was successfully managed with supportive care in our PICU.

Causative agent

Bordetella pertussis.
Gram – negative

Mode of transmission

Respiratory droplets.
Highly contagious, especially in catarrhal stage.

Incubation period: 7 – 10 days (up to 21 days).

Stages of pertussis

Catarrhal stage (1-2 weeks)

Mild fever.
Runny nose.
Sneezing
Mild cough.

Paroxysmal stage: (2-6 weeks)

Severe coughing spells.
Inspiratory “whoop”.
Post-tussive vomiting.
Apnoea, cyanosis(infants).

Convalescent stage(weeks-months)

Gradual decrease in coughing.
Recovery phase.

Critical pertussis

Critical pertussis refers to severe, life-threatening pertussis, most seen in young infants (<6 months). It is characterized by respiratory failure, recurrent apnoea, pulmonary hypertension, severe leucocytosis, and may rapidly progress to cardiogenic shock and death despite standard therapy.

Clinical Features

Recurrent apnoea (often without classic whoop).
Severe paroxysmal cough.
Cyanosis
Bradycardia.
Seizure (secondary to hypoxia).
Poor feeding and exhaustion.
Post tussive vomiting.
Leucocytosis with lymphocytosis.
Possible pneumonia or atelectasis.

Laboratory Findings

Marked leucocytosis with lymphocytosis (WBC often >50,000- 100000).
Hypoxemia on blood gases.
PCR from nasopharyngeal swab.

Pathophysiology of severity (critical point)

Pertussis toxin causes

Extreme lymphocytosis
↓
Leukocyte aggregation in pulmonary vessels
↓
Increased pulmonary vascular resistance
↓
Decreased cardiac output

Management

Management requires early recognition, intensive care, and aggressive supportive therapy.

Airway& Breathing

Maintain patent airway.
Position infant with head elevated.
Gentle suctioning (avoid over-suctioning can trigger coughing).
Administer humidified oxygen.
Monitor apnoea and cyanosis.
Continue pulse oximetry.

Medication Administration

Macrolide antibiotics (Azithromycin, clarithromycin or erythromycin).
Monitor for side effects (especially GI upset).
Prophylactic antibiotics for close contacts as orders.

Medical Management of Hyperleukocytosis

Severe leucocytosis is strongly associated with mortality. (Total WBC count >50,000 cells/).
Only symptomatic hyperleukocytosis should be treated with either drugs like hydroxyurea or Leukapheresis, exchange transfusion.

Cardiopulmonary Monitoring

Continuous cardiac and respiratory monitoring
Watch for:
- Bradycardia during coughing
- Signs of pulmonary hypertension
- Assess ABG if severe respiratory distress

Seizure & Apnoea Control

Treat seizure with appropriate anticonvulsants
Apnoea management
- Caffeine (in infants)
- Ventilator support if recurrent

Nutritional Support and Hydration

Small, frequent feeds
NG feeds or IV Fluids if:
- Severe coughing
- Poor oral intake
Monitor weight, intake/output
Prevent aspiration during coughing episode

Infection Control

Droplet precautions.
Chemoprophylaxis for close contacts (macrolides).

Prevention (Most important Long -Term Measure)

Maternal Tdap vaccination during each pregnancy.
Timely infant vaccination (DTaP).
Booster doses in adolescents and adult.

Case presentation

A 54-day old male child admitted with cough for 6 days, fast breathing and decreased urine output for 2 days, fever for one day. He was admitted and treated for one day with face mask oxygen, IVF and IV Antibiotics, before being referred to our hospital for further management.

Antenatal history: Nil significant.

Birth history

Term/Normal vaginal delivery/No postnatal complications.
Birth weight – 2.8kg.

Immunization history

Birth vaccine was given.
6^th week vaccination was not given.

Developmental history

Gross motor: Partial neck holding.
Fine motor: Palmar grasp.
Language: Cooing.
Social: Recognize and smiles at mother.

Family history

History of upper respiratory infection in elder sibling.
Second born of non-consanguineous marriage.

Someway presented with the complaints of:

Repeated coughing spells (paroxysmal cough).
Whoop sound after cough.
Vomiting after cough.
Poor feeding.
Exhaustion
Thick secretions.

Management

Child received in emergency with tachypnoea, tachycardia, subcostal and suprasternal retraction and bilateral conducted sounds and hypoxemia suggesting respiratory failure. He was started on nasal prongs oxygen, IVF, Inj. Cefotaxime and 3% NS and adrenaline nebulization. However, in view of persistent respiratory distress, HFNC support was started. Lung POCUS (Point of care Ultrasound) showed shreds with consolidation in the right posterior apical zone and consolidation in the left posterior basal zone with no evidence of pleural effusion, while cardiac POCUS was normal. Initial diagnosis of acute viral bronchiolitis was considered, and he was shifted to PICU for respiratory monitoring.

Investigations

Admission blood investigation showed anaemia with lymphocytic leucocytosis and thrombocytosis. Nasopharyngeal swab of influenzas and RSV PCR was negative. Child was noted to have intermittent paroxysmal cough with post -tussive tachypnoea and tachycardia. Child didn’t receive 6^thweek of immunization and CBC showed significant lymphocytosis; hence, possibility of critical pertussis was considered, and he was started on oral Azithromycin and nasopharyngeal swab for pertussis PCR was sent. It was strongly positive. He was isolated and close contacts were given azithromycin prophylaxis. Repeat blood investigations showed persistent anaemia, worsening lymphocytosis (Total WBC count >50,000 cells) and thrombocytosis with normal renal function test. Peripheral smear showed mild normocytic normochromic anaemia with increased polychromatophilic cells and thrombocytosis, lymphocytosis with occasional reactive lymphocytes. His respiratory distress was persistent. In view of symptomatic hyperleukocytosis he was given three doses of oral hydroxyurea. His respiratory distress gradually improved over next 24 hrs. HFNC Support was tapered, and he was weaned off to room air. After 48 hrs of PICU stay, repeat CBC showed a declining trend in white blood cells and platelet counts with normal electrolytes and renal function test. Subsequently he remained alert, afebrile, hemodynamically stable without respiratory distress, with intermittent paroxysmal cough and tolerated direct breast feeding well. Child was discharged on day 8 of hospital stay and advised home isolation for 13 more for days a total duration of 21 days. Child was followed up after two weeks. Her cough settled; child was active and weight gain was adequate.

Date	03/01/26	04/01/26	06/01/26	08/01/26
Hemoglobulin	9.3	9.8	9.9	10.1
PCV	29.7	31.4	31.8	32
Platelet	813000	771000	603000	822000
Total count (WBC)	49720	51950	45480	38540
Differential counts (N/L/E/M)	25.8/64.6 1.2/8.1	25.9/67.6 1.8/4.9	22.7/68.0 1.5/7.5	20.7/71.9 1.7/5.4
Creatinine	-	0.19	0.16	-
Sodium	-	-	134	-
Potassium	-	-	4.0	-
Chloride	-	-	98	-
Bicarbonate	-	-	28.8	-
CRP	-	-	1.030	-
Nasopharyngeal swab for influenza and RSV PCR: Negative
Nasopharyngeal swab for pertussis: Positive

Nursing Management

Followed and adhered the isolation protocol & Infection Control policies, respectively. Maintained droplet precautions (face mask, hand hygiene) for all medical personnel. Isolated the infant to prevent spread of infection. Educated the nurses on cough etiquette. Prevented iatrogenic injury by complete nursing care. Patent airway maintained. Positioned in semi-Fowler to ease breathing. Monitored respiratory rate, work of breathing, and oxygen saturation. Provided humidified oxygen. Applied gentle suctioning to clear secretions frequently. Kept emergency equipment ready (Apnoea risk in infants) -AMBU. Observed for apnoea, cyanosis, bradycardia. Monitored spo2 continuously. Provided small, frequent feeds to prevent vomiting (Breast milk. NG feeds if oral feeding is unsafe. Monitored intake/output and daily weight. Administered IV fluids, feeding is poor or vomiting is severe. Administered antibiotics, antipyretics, nebulization as prescribed. Maintained a quiet, calm environment. Explained disease course and prolonged cough phase. Educated on warning signs: apnoea, bluish colour, poor feeding. Emphasized on immunization (DTaP) for infant Recorded frequency and severity of coughing spells. Documented feeding tolerance and oxygen needs. Nursing health education given on further management and prevention of pertusis.

Medicine Advice on discharge

S. No	Drug name /Strength	Frequency			Route of admin	Relationship with meal	Days
		M	A	N
1	Multivitamin	0.5mL	0	0	Oral	After food	5 Days
2	Domperidone 1 Mg /1mL	0.6 mL	0.6 mL	0.6 mL	Oral	Before food	5 Days
3	Nebuliser with 3 % Sodium Chloride	4 mL	4 mL	4 mL	Nasal	-	3 Days
4	Rash free Ointment	1	1	1	L/A	-	(SOS)
5	Paracetamol 125Mg /5mL	2.5 ml	2.5 ml	2.5 ml	Oral	After food	(SOS) for Fever

Conclusion

This case highlights the importance of early recognition and prompt management of pertussis in infancy, a population at high risk for severe complications. Timely diagnosis, appropriate antibiotic therapy, close monitoring of respiratory status, and comprehensive supportive nursing care contributed significantly to the favorable outcome in this patient. Strict infection control measures and parental education played a key role in preventing disease transmission and ensuring continuity of care after discharge. The successful recovery and discharge of the infant emphasizes that early intervention and multidisciplinary care are crucial in reducing morbidity and improving outcomes in pertussis among young infants.

Critical pertussis

Critical pertussis

Nivetha M1*, Gayathri Devi V1, Sonya Mercy Anbu2, Ruby3

Nightingale Journals

Nivetha M^1*, Gayathri Devi V¹, Sonya Mercy Anbu², Ruby³