A 34 year old Hispanic woman presents to the clinic with cough, head congestion, possible fevers and sneezing. This has been going on for 2-3 days. She also has had trouble breathing due to the coughing, and has a history of asthma. Nobody else in the home is sick. She has no other relevant past medical history. Her main concern is that she might get her infant child sick. However, she says both she and child are up to date on their vaccines. She says she got a Tdap shot at the hospital while pregnant.
The exam was repeatedly interrupted by the patient’s coughing fits. She often had to stand up from the exam table due to the intense coughing spasms that left her gasping for air. The gasps were loudly audible with a high-pitched, airy roar. The patient said she otherwise felt fine in between these coughing spasms; the head congestion was no big deal. The patient’s vital signs, including her oxygen saturation, were normal. The lungs sounded clear on exam. A chest X-ray was unremarkable.
AT THIS POINT, I WAS 99% SURE OF THE DIAGNOSIS. WHAT IS YOUR GUESS?
Catarrhal/paroxysmal infection with Bordetella pertussis, aka whooping cough
The diagnosis was confirmed by laboratory testing, which triggered a report to the health department. I credit my cynicism towards our wonderful health care system for being open to the diagnosis, for reasons we’ll get to shortly.
Pertussis was once a classic illness of childhood, right up with measles and mumps. The characteristic whooping (I tried my best to describe it without using the word “whooping”) is caused by the desperate gasping for breath after the coughing spasms render inspiration impossible.
The bacteria itself seems to not be so bad. It produces the cold-like “catarrhal” stage, with congestion, runny nose, and low-grade temperature; it is rare for the illness to be diagnosed at this stage.
But it is the toxin it produces that is the real problem, similar to how it’s tetanus toxin that causes lockjaw and not the tetanus bacteria itself. It is this pertussis toxin that brings on the worst aspect of pertussis: the “paroxysmal,” or whooping, phase. Researchers believe this toxin breaks down respiratory membranes in the upper respiratory system, and the resulting mixture of dead cells and snot gets breathed in, thus triggering the characteristic coughing fits. Even after the bacteria gets killed off with antibiotics or by the body’s natural defense systems, the cough persists due to the lingering toxin.
Treatment options are limited. I caught the patient as she was transitioning from the catarrhal to the paroxysmal phase; I gave her a Z-pak on her initial visit, which likely cut the duration of the illness somewhat. But even so, there is no question her coughing spasms are going to hang around for a month or longer due to the toxin. A strong cough syrup with codeine gave only mild relief; the patient still has trouble sleeping due to the fits. Asthma inhalers provided no relief. The health department suggested Benadryl, but research shows lack of benefit from that either. Many patients wind up sedated and intubated in the ICU from this preventable illness.
I mentioned that pertussis is no longer a classic illness of childhood. There is one major exception, though: the children of that class of moron we lovingly term anti-vaxxers. Here, for instance, is the tale of the mother of the year candidate who allowed all seven of her poor children to catch this major illness because she trusted conspiracy theorists over people who know what the hell they’re talking about. It took this disaster to make this genius consider that, you know, maybe vaccines actually do exist for a reason. (Credit where credit is due, though: at least she changed her mind. Most anti-vaxxers, like all other morons of every stripe, are constitutionally incapable of changing their irrational beliefs. In fact, the greater a moron’s beliefs are challenged, the more strongly he or she holds on to them!)
Anti-vaxxers have thus allowed to persist a human “reservoir” of pertussis, to afflict people like my undeserving patient. But in a more sane world, pertussis would have gone the way of smallpox. You see, just like smallpox, pertussis solely affects humans. There is no animal “reservoir” to keep the germ alive. Therefore, a total campaign of vaccination would have killed it off by now… but due to the Jenny McCarthys of the world, this will probably never happen. Don’t underestimate her influence: poor Jim Carrey was left incoherent on the subject due to years of her mental dominance, even five years after their breakup. (Have I mentioned before that you need to be damn careful before choosing to date someone more alpha than you?)
As far as that Tdap (the “p” stands for pertussis) vaccine she mentioned to me: The only way this case makes sense is if you grant that someone at the hospital screwed up, and gave her the wrong vaccine; or else, that batch of vaccines was bad. If I had trusted that such a mistake would be unthinkable in our well-oiled (guffaw) medical machine, I would have never treated my poor patient for pertussis until the test came back. And by then, it would have been too late to make much difference.
Also: remember that I said she was pregnant six months ago… due to the screw-up, there is now an infant at risk. This is the patient population that experiences, by far, the greatest mortality from pertussis. The child would have had shots at 2, 4, and 6 months of age — assuming the grab the correct vials. A baby’s greatest immune protection comes from his mother, though — and, obviously, the mother lacked any real immunity to pertussis to pass on to the child.
The health department recommended all her family members be treated, including their infant, and then they took over the case. My patient was fortunate enough to be young and healthy, but even she might have ended up in the ICU, literally on life support, if she had been unluckier.
Having a medical case caused by pure human stupidity is hardly novel, as July 4th fireworks prove every year. But the crime here was that my patient had to suffer because of other peoples’ stupidity. Please don’t be stupid. Please vaccinate your kids.