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May 14, 2014

Whooping Cough Without the Whoop - The Bad Lingering Cough

Although I have been practicing medicine since 2000, the first time I diagnosed whooping cough was in 2011 and ever since, I have been diagnosing more and more cases each year thereafter. However, what makes these cases a little unusual is that for ALL cases of whooping cough I have diagnosed, there was no characteristic whoop for which it is named after.

Rather, the common characteristics for all patients I have diagnosed include:

"Mystery" cough that has been going on for weeks if not months
• Cough can occur in severe attacks with in-between periods of relative normalcy. Cough could also be just a "bad, lingering" cough.
• Cough attacks can be so severe, patient may get short of breath, faint, turn blue, vomit, etc. However, they could be minor attacks as well.
• Dry cough, though some mucus may be seen
• All studies like lung function tests and chest x-rays (save those described below) come back normal.
• Medications typically do not work except for strong narcotic cough suppressants.
• No whoop after the cough.
• Afflicts ALL ages

Should a person been coughing like this only in the past week, I usually obtain a nasopharyngeal swab tested for bordetella pertussis DNA.


If it has been for longer than a few weeks and antibiotics have been given, I usually obtain blood titres for bordetella pertussis mainly because the infectious agent may have been cleared and culture may come back falsely negative. Such blood tests include pertussis toxin, filamentous hemagglutinin, and/or fimbrial agglutinin IgG/IgA titres.

My personal observations have also been reported elsewhere.

In fact, a study in 2010 stated that the "classic" symptoms of whooping cough which historically was considered only a childhood disease, is no longer a reliable way of determining whether a patient has whooping cough or not. It is also no longer a childhood disease.

In fact, most teens and adults lack the classic symptoms for whooping cough and their only symptom may be a bad lingering cough. In fact, some estimate that 10% to 30% of prolonged coughs in adults are caused by pertussis.

Even if a patient has been vaccinated for whooping cough, you can STILL get it mainly because it is not 100% effective. Furthermore, vaccine protection fades with time. Given incomplete ineffectiveness in combination with more and more parents electing to not vaccinate their kids, it is no surprise there are more cases being diagnosed every year. It's just that physicians may not recognize the cough for what it is.

Here's what the CDC has to say about whooping cough vaccines:
Vaccine protection for pertussis, tetanus, and diphtheria can fade with time. Before 2005, the only booster vaccine available contained tetanus and diphtheria (called Td), and was recommended for adolescents and adults every 10 years. Today there are boosters for adolescents and adults that contain tetanus, diphtheria, and pertussis (called Tdap). Pre-teens going to the doctor for their regular check-up at age 11 or 12 years should get a dose of Tdap. Adults who didn’t get Tdap as a pre-teen or teen should get one dose of Tdap instead of the Td booster. Most pregnant women who were not previously vaccinated with Tdap should get one dose of Tdap postpartum before leaving the hospital or birthing center. Getting vaccinated with Tdap is especially important for families with and caregivers of new infants.

The easiest thing for adults to do is to get Tdap instead of their next regular tetanus booster—that Td shot that they were supposed to get every 10 years. The dose of Tdap can be given earlier than the 10-year mark, so it’s a good idea for adults to talk to a health care provider about what’s best for their specific situation. [link]
Of course, there may be other causes for a chronic lingering cough, but whooping cough should be in the differential.


References:
Diagnosis and Laryngeal Complications of Bordatella pertussis Infection in the Ambulatory Adult Population. Otolaryngol Head Neck Surg. 2014 Sep 9. pii: 0194599814549316.

Does this coughing adolescent or adult patient have pertussis? JAMA. 2010 Aug 25;304(8):890-6. doi: 10.1001/jama.2010.1181.

No big whoop: Adult pertussis may not produce the whooping cough. Harvard Health Blog 9/13/10
Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids. Google+ Christopher Chang, MD Bio

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