Case Presentation: A partially vaccinated 8-year-old female presented with 1 week of recurrent spasms and choking episodes. Episodes occurred daily, and were characterized by gasping, choking, and body stiffening lasting 2-3 minutes, often waking her from sleep. Her family was unable to abort these episodes, and it was unclear whether she remained conscious during these episodes. She had a mild cough 2 weeks prior. The patient had multiple evaluations, however, work-up including chest x-ray, abdominal x-ray, and video EEG were normal. She was started on famotidine, omeprazole, and sucralfate. She was admitted because episodes were occurring more frequently. In the emergency department, the patient had an observed episode with choking, severe gasping, and shaking followed by apparent decreased responsiveness. The patient maintained appropriate vitals throughout the episode. A head CT was normal. She was admitted to the pediatric intermediate care unit initially. During this hospitalization, gastroenterology, neurology, otolaryngology, and pulmonology were consulted. Labs such as basic metabolic panel, complete blood count, urine drug screen, and urinalysis were normal. She underwent EEG, EKG, modified barium swallow, upper GI X-ray series, and flexible laryngoscopy which were also unremarkable. While admitted, she continued to have episodes which resolved spontaneously. The medical team suspected that the severe gasping observed may represent a “whoop.” A respiratory pathogen panel was then obtained and was positive for pertussis. Further history revealed previously undisclosed household contacts recently diagnosed with pertussis. She started a 5-day course of azithromycin and was discharged home. Contact tracing was pursued following the diagnosis to provide appropriate post-exposure prophylaxis to the many healthcare workers exposed to the patient.
Discussion: Pertussis is caused by the gram-negative bacteria, Bordetella pertussis. It is well-characterized to have 3 distinct phases: catarrhal lasting 1-2 weeks, paroxysmal lasting 2-8 weeks, and convalescent lasting for months. The eponymous “whoop” is most often observed in infants and rarely seen in older children. Pertussis is vaccine-preventable; however, its incidence is increasing due to a national decline in vaccinations rates. As incidence of cases increases, healthcare providers must be familiar with the differing presentations of this illness to prevent delays in diagnosis which result in both increased morbidity in affected children and potential transmission to others.
Conclusions: This case demonstrates an atypical presentation of pertussis in a child, resulting in an extended course prior to diagnosis. Following diagnosis, contact tracing was pursued as this patient had many interactions, including with healthcare professionals in emergency departments, hospital units, and urgent care offices. Soon after discharge for this admission, the patient returned to care as episodes were ongoing. Further education was provided to the family that the patient was in the paroxysmal stage and could anticipate symptoms for weeks-to-months even after treatment.