Epidemics due to Bordetella pertussis still occur every 3-4 years though most infections are mild or subclinical. However, pertussis can prove fatal to an infant who has not been vaccinated such as the case we present of fulminant pertussis in unvaccinated twins.
A 1-month old unvaccinated boy was referred to our hospital with fever of unknown origin. He had not been drinking well and had an intermittent cough. His mother and older brother also complained of a cough. On referral, the patient had normal breathing and oxygen saturation but on auscultation there were respiratory crackles in the right upper lung. A lobar pneumonia was confirmed on thoracic X-ray. The leukocytes were within the normal range for his age (16.1x109/l) with slightly elevated lymphocytes and a C-reactive protein (CRP) of 46 mg/ml. Viral or bacterial pneumonia was suspected so he was admitted to our ward and started amoxicillin. The respiratory symptoms progressed such that oxygen supplementation was required over the next few days. Meanwhile his twin sister was admitted with similar symptoms also suspected to be due to a viral infection. Two days after admission her brother’s condition suddenly deteriorated and he was transferred to the paediatric intensive care unit where he was intubated because of respiratory failure. The diagnostic work-up showed leucocytosis of 68.9x109/l, an elevated CRP of 210 mg/ml and hyponatraemia (128 mmol/l). Pertussis was suspected and erythromycin was started intravenously. Around 24 hours later he deteriorated further with severe pulmonary hypertension and we suspected malignant pertussis. Extra-corporal membrane oxygenation (ECMO) was indicated, however, before cannulation he died of refractive pulmonary hypertension. Nasopharyngeal cultures yielded Bordetella pertussis.
Meanwhile, his twin sister was admitted to the paediatric intensive care unit also with respiratory failure though echocardiography showed no pulmonary hypertension. However within 24 hours her condition suddenly deteriorated with the development of severe pulmonary hypertension. She was started on ECMO but despite extensive treatment, which included leukocyte filtration, there was little response and she died 3 weeks later.
We present a case of fatal pertussis in two unvaccinated twins. The course of pertussis is not specific and can present as an apparent viral respiratory disease. However, in young infants, the disease can progress to fulminant pertussis as in this case. Most cases of pertussis in infants are the result of transmission from family members who have silent disease that escapes recognition. It is important that pertussis is considered when a patient presents with a persistent explosive cough and antibiotics should be started if the patient is in the third trimester of pregnancy or when there is an infant < 6 months in the family. It is not only important that paediatricians consider pertussis, but that general practitioners, midwifes and gynaecologists are alert as well.
In the Netherlands, it is time to reconsider our current vaccination programme because of the persisting occurrence of pertussis and the recent rise in incidence. Different strategies must be considered to reduce the transmission from pertussis to vulnerable infants, such as adolescent vaccination, cocooning or maternal vaccination.
This supplementary information is presented as submitted by the corresponding author. It has not been copy-edited by NTvG.