Question

Difficulty: MediumPediatric Respiratory Disorders

A 1010-week-old female infant is brought to the pediatric emergency department by her parents due to severe spells of coughing. The mother reports that the infant had a runny nose, mild cough, and tactile fever for about a week. Over the past 55 days, the cough has worsened significantly, occurring in sudden, rapid bursts. During these episodes, the infant's face turns red, and she makes a high-pitched "whooping" sound when she finally catches her breath. She has vomited her formula after several of these coughing spells. The infant has not received any routine immunizations because the family recently immigrated. Vital signs between episodes are temperature 37.1∘C37.1^\circ\text{C} (98.8∘F98.8^\circ\text{F}), pulse 140140/min, and respirations 4040/min. Physical examination between coughing spells shows a well-appearing infant with clear lungs on auscultation. Laboratory studies reveal a leukocyte count of 24,000/mm324,000/\text{mm}^3 with 72%72\% lymphocytes. Which of the following is the most appropriate next step in management?

  1. Administration of oral azithromycinAnswer
  2. B
    Administration of oral amoxicillin
  3. C
    Administration of nebulized albuterol
  4. D
    Administration of the diphtheria, tetanus, and acellular pertussis vaccine
  5. E
    Supportive care with humidified oxygen and nasal suctioning

Answer

Administration of oral azithromycin
The correct intervention is the administration of oral azithromycin. This unimmunized infant's clinical presentation (paroxysmal cough, inspiratory whoop, post-tussive emesis) and laboratory findings (leukocytosis with a strong lymphocytic predominance) are highly characteristic of an infection with Bordetella pertussis. The primary goal of antibiotic therapy during the paroxysmal phase of pertussis is to eradicate the organism from the nasopharynx, thereby halting transmission. Macrolide antibiotics, particularly azithromycin, are the drugs of choice.

Step-by-Step Solution

1
Analyze the patient's symptoms and history.
The infant presents with a paroxysmal cough, inspiratory whoop, and post-tussive emesis, following a 1-week catarrhal phase. She is also unimmunized.
These are the classic features of the paroxysmal stage of whooping cough, caused by the bacterium Bordetella pertussis.
2
Interpret the laboratory findings.
The complete blood count shows significant leukocytosis (24,000/mm324,000/\text{mm}^3) with a marked lymphocyte predominance (72%72\%).
Bordetella pertussis produces pertussis toxin, which inhibits lymphocyte migration into lymphoid tissues, leading to profound lymphocytosis in the peripheral blood. This helps distinguish it from other viral or bacterial respiratory illnesses.
3
Determine the most appropriate management.
A macrolide antibiotic, such as oral azithromycin, should be administered.
Macrolides are the treatment of choice for pertussis. While they may not significantly alter the clinical course if started during the paroxysmal phase, they are essential to eradicate the bacteria from the nasopharynx and prevent transmission to others.

Key Concept

The diagnosis of Bordetella pertussis relies on recognizing the paroxysmal cough, inspiratory whoop, post-tussive emesis, and marked lymphocytosis. The treatment of choice is a macrolide antibiotic (e.g., azithromycin) to reduce transmissibility.
Estimated Time:1m 0s
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