Pertussis infection in adolescents and adults: Clinical manifestations and diagnosis
- Paul Cornia, MD
Paul Cornia, MD
- Associate Professor of Medicine
- University of Washington
- Benjamin A Lipsky, MD, FACP, FIDSA, FRCP
Benjamin A Lipsky, MD, FACP, FIDSA, FRCP
- Emeritus Professor of Medicine
- University of Washington
- Visiting Professor of Medicine
- Teaching Associate, Green Templeton College
- University of Oxford
Pertussis, also known as "whooping cough," is a highly contagious, acute respiratory illness caused by Bordetella pertussis. In the prevaccine era, the disease predominantly affected children <10 years of age and usually manifested as a prolonged cough illness with one or more of the classical symptoms: inspiratory whoop, paroxysmal cough, and posttussive emesis .
Since the introduction of pertussis vaccines, the epidemiology of reported pertussis infections has changed; in the United States in the 1990s, more than one-half of cases occurred in adolescents and adults . Infected adolescents and adults serve as a reservoir for infection of infants and children in whom serious morbidity and mortality may occur. Symptoms and signs in adolescents and adults are often nonspecific, and the diagnosis may not be considered.
Clinical manifestations and diagnosis of pertussis will be reviewed here. Issues related to the pathogenesis, epidemiology, treatment, and prevention of pertussis are discussed separately. (See "Pertussis infection: Epidemiology, microbiology, and pathogenesis" and "Pertussis infection in adolescents and adults: Treatment and prevention" and "Pertussis infection in infants and children: Clinical features and diagnosis" and "Pertussis infection in infants and children: Treatment and prevention".)
The incubation period following exposure is typically 7 to 10 days but may be three weeks or longer . This incubation period is considerably longer than that of common upper respiratory infections, such as the common cold (one to three days). Infection with B. pertussis in individuals without preexisting immunity is characterized by three phases: the catarrhal phase, the paroxysmal phase, and the convalescent phase. In infected adolescents or adults with a history of prior infection or vaccine-induced immunity, classic symptoms may or may not occur.
Catarrhal phase — The catarrhal phase is the earliest phase of illness, lasting one to two weeks, and is characterized by nonspecific symptoms including generalized malaise, rhinorrhea, and mild cough. Slight temperature elevations may be present, but high fever is uncommon . Two early clinical findings suggestive of pertussis are excessive lacrimation and conjunctival injection. Diagnostic tests are most accurate during this phase; however, the nonspecific clinical manifestations rarely lead to suspicion of pertussis. (See 'Approach to diagnosis' below.)
- Güriş D, Strebel PM, Bardenheier B, et al. Changing epidemiology of pertussis in the United States: increasing reported incidence among adolescents and adults, 1990-1996. Clin Infect Dis 1999; 28:1230.
- Centers for Disease Control and Prevention (CDC). Pertussis--United States, 1997-2000. MMWR Morb Mortal Wkly Rep 2002; 51:73.
- Heininger U, Cherry JD, Stehr K, et al. Comparative Efficacy of the Lederle/Takeda acellular pertussis component DTP (DTaP) vaccine and Lederle whole-cell component DTP vaccine in German children after household exposure. Pertussis Vaccine Study Group. Pediatrics 1998; 102:546.
- Mattoo S, Cherry JD. Molecular pathogenesis, epidemiology, and clinical manifestations of respiratory infections due to Bordetella pertussis and other Bordetella subspecies. Clin Microbiol Rev 2005; 18:326.
- Rutledge RK, Keen EC. Images in clinical medicine. Whooping cough in an adult. N Engl J Med 2012; 366:e39.
- Centers for Disease Control and Prevention. Pertussis (Whooping Cough). http://www.cdc.gov/pertussis/materials/hcp.html (Accessed on June 29, 2016).
- Couzigou C, Flahault A. Is pertussis being considered as a cause of persistent cough among adults? Eur J Epidemiol 2003; 18:1013.
- Cornia PB, Hersh AL, Lipsky BA, et al. Does this coughing adolescent or adult patient have pertussis? JAMA 2010; 304:890.
- Teepe J, Broekhuizen BD, Ieven M, et al. Prevalence, diagnosis, and disease course of pertussis in adults with acute cough: a prospective, observational study in primary care. Br J Gen Pract 2015; 65:e662.
- De Serres G, Shadmani R, Duval B, et al. Morbidity of pertussis in adolescents and adults. J Infect Dis 2000; 182:174.
- Karki S, McIntyre P, Newall AT, et al. Risk factors for pertussis hospitalizations in Australians aged 45 years and over: A population based nested case-control study. Vaccine 2015; 33:5647.
- Pratter MR, Brightling CE, Boulet LP, Irwin RS. An empiric integrative approach to the management of cough: ACCP evidence-based clinical practice guidelines. Chest 2006; 129:222S.
- Pratter MR. Cough and the common cold: ACCP evidence-based clinical practice guidelines. Chest 2006; 129:72S.
- Centers for Disease Control and Prevention. Pertussis (Whooping Cough). Surveillance & Reporting. http://www.cdc.gov/pertussis/surv-reporting.html.
- World Health Organization. WHO-recommended surveillance standard of pertussis. http://www.who.int/immunization_monitoring/diseases/pertussis_surveillance/en/index.html.
- Patriarca PA, Biellik RJ, Sanden G, et al. Sensitivity and specificity of clinical case definitions for pertussis. Am J Public Health 1988; 78:833.
- Centers for Disease Control and Prevention. Pertussis (Whooping Cough). Diagnosis Confirmation. http://www.cdc.gov/pertussis/clinical/diagnostic-testing/diagnosis-confirmation.html.
- Hewlett EL, Edwards KM. Clinical practice. Pertussis--not just for kids. N Engl J Med 2005; 352:1215.
- von König CH, Halperin S, Riffelmann M, Guiso N. Pertussis of adults and infants. Lancet Infect Dis 2002; 2:744.
- World Health Organization. WHO-recommended surveillance standard of pertussis. http://www.who.int/immunization/monitoring_surveillance/burden/vpd/surveillance_type/passive/pertussis_standards/en/ (Accessed on November 12, 2014).
- Cherry JD, Grimprel E, Guiso N, et al. Defining pertussis epidemiology: clinical, microbiologic and serologic perspectives. Pediatr Infect Dis J 2005; 24:S25.
- Broder KR, Cortese MM, Iskander JK, et al. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006; 55:1.
- Centers for Disease Control and Prevention. Pertussis (Whooping Cough): Materials. http://www.cdc.gov/pertussis/materials/hcp.html (Accessed on June 29, 2016).
- Centers for Disease Control and Prevention. Pertussis (whooping cough). Specimen collection. www.cdc.gov/pertussis/clinical/diagnostic-testing/specimen-collection.html (Accessed on November 12, 2014).
- Müller FM, Hoppe JE, Wirsing von König CH. Laboratory diagnosis of pertussis: state of the art in 1997. J Clin Microbiol 1997; 35:2435.
- Schläpfer G, Cherry JD, Heininger U, et al. Polymerase chain reaction identification of Bordetella pertussis infections in vaccinees and family members in a pertussis vaccine efficacy trial in Germany. Pediatr Infect Dis J 1995; 14:209.
- Schmidt-Schläpfer G, Liese JG, Porter F, et al. Polymerase chain reaction (PCR) compared with conventional identification in culture for detection of Bordetella pertussis in 7153 children. Clin Microbiol Infect 1997; 3:462.
- Lievano FA, Reynolds MA, Waring AL, et al. Issues associated with and recommendations for using PCR to detect outbreaks of pertussis. J Clin Microbiol 2002; 40:2801.
- Fry NK, Tzivra O, Li YT, et al. Laboratory diagnosis of pertussis infections: the role of PCR and serology. J Med Microbiol 2004; 53:519.
- Faulkner AE, Skoff TH, Tondella ML, et al. Trends in Pertussis Diagnostic Testing in the United States, 1990 to 2012. Pediatr Infect Dis J 2016; 35:39.
- Stehr K, Cherry JD, Heininger U, et al. A comparative efficacy trial in Germany in infants who received either the Lederle/Takeda acellular pertussis component DTP (DTaP) vaccine, the Lederle whole-cell component DTP vaccine, or DT vaccine. Pediatrics 1998; 101:1.
- Vincent JM, Cherry JD, Nauschuetz WF, et al. Prolonged afebrile nonproductive cough illnesses in American soldiers in Korea: a serological search for causation. Clin Infect Dis 2000; 30:534.
- Simondon F, Iteman I, Preziosi MP, et al. Evaluation of an immunoglobulin G enzyme-linked immunosorbent assay for pertussis toxin and filamentous hemagglutinin in diagnosis of pertussis in Senegal. Clin Diagn Lab Immunol 1998; 5:130.
- Guiso N, Berbers G, Fry NK, et al. What to do and what not to do in serological diagnosis of pertussis: recommendations from EU reference laboratories. Eur J Clin Microbiol Infect Dis 2011; 30:307.
- Bisgard KM, Christie CD, Reising SF, et al. Molecular epidemiology of Bordetella pertussis by pulsed-field gel electrophoresis profile: Cincinnati, 1989-1996. J Infect Dis 2001; 183:1360.
- Brennan M, Strebel P, George H, et al. Evidence for transmission of pertussis in schools, Massachusetts, 1996: epidemiologic data supported by pulsed-field gel electrophoresis studies. J Infect Dis 2000; 181:210.
- Nouvellon M, Gehanno JF, Pestel-Caron M, et al. Usefulness of pulsed-field gel electrophoresis in assessing nosocomial transmission of pertussis. Infect Control Hosp Epidemiol 1999; 20:758.