whooping cough

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Classification according to ICD-10
A37.0 Whooping cough from Bordetella pertussis
A37.1 Whooping cough due to Bordetella parapertussis
A37.8 Whooping cough from other Bordetella species
A37.9 Whooping cough, unspecified
ICD-10 online (WHO version 2019)

Whooping cough (also pertussis , Latin for strong cough ; popularly sticky cough , formerly also tussis convulsiva ) is a highly contagious respiratory disease caused by the bacterium Bordetella pertussis , more rarely by Bordetella parapertussis , which is characterized by typical coughing attacks .

The infection takes place via body fluids, especially the respiratory tract ( droplet infection ). After an unspecific initial stage, it usually takes several weeks. The initial stage with a cold-like cough, which is called the catarrhale stage , is followed in the convulsive stage with typical staccato-like coughing attacks. In infants, the coughing fits can atypically manifest themselves as respiratory arrest and thus be life-threatening. Finally, in the decrementi stage, the coughing attacks gradually decrease in number and severity . Causal therapy is only possible in the early stages. A generally recommended effective vaccination exists for prophylaxis .

Whooping cough is a reportable disease in Germany and Austria .

Pathogen

Bordetella pertussis under the light microscope (Gram stain)

Bordetella pertussis , the causative agent of whooping cough, is an immobile, aerobic, encapsulated gram-negative rod bacterium . It produces many different proteins , some of the toxins , the disease symptoms cause, some are responsible for ensuring that the pathogen well to the mucous membranes of the respiratory tract adhere and multiply there ( virulence factors ). An infection with Bordetella parapertussis only leads to the clinical picture of whooping cough in less than a fifth of cases. 40% of infections are silent and another 40% are simple acute bronchitis .

Epidemiology

The only pathogen reservoir for Bordetella pertussis is humans. It would therefore be fundamentally possible to eradicate the disease through a consistent vaccination of all humanity. There is also a reservoir for Bordetella parapertussis in sheep. Around 17 million people worldwide contracted whooping cough in 2003, 90% of them in developing countries. In the same year, there were approximately 280,000 deaths from whooping cough. For the new federal states of Germany, surveys show that the number of illnesses is increasing. This statement can only be made for the new federal states, because only there was a reporting requirement for whooping cough before 2013. The data has been collected since at least 2002. In 2004 there were 12.3 diseases per 100,000 inhabitants in the new federal states ( incidence ); ten years earlier there were only 3.4 cases per 100,000 inhabitants. In 2011, according to the Robert Koch Institute, almost 4,200 whooping cough cases were reported in eastern Germany (28 cases per 100,000 inhabitants). The earlier lower number of whooping cough disease explained by the fact that in the GDR a compulsory vaccination was. After the reunification of Germany , vaccinations became voluntary health protection measures in the new federal states as well. As a result, vaccination rates fell.

The whooping cough bacteria are transmitted by droplet infection, with large droplets that the sick person coughs up through the air they breathe into the body of the contact person. The brothels are extremely infectious . 80 to 100% of people who come into contact with the pathogen become ill. The incubation period is 7 to 14 (up to 21) days. Infectiousness begins towards the end of the incubation period, is highest during the catarrhal stage and gradually subsides in the convulsive stage . Neither the vaccination nor the illness you have suffered guarantee lifelong immunity . It is therefore possible and quite common to contract pertussis several times in a lifetime. In countries with a high vaccination rate, young people and adults tend to get sick. These play an important role as carriers of the pathogens.

Symptoms

Boy with a typical whooping cough attack
Female infant with a typical whooping cough attack, note the protruding tongue

The disease classically goes through three stages: stage catarrhale, stage convulsivum and stage decrementi. In newborns and infants, however, as in adolescents and adults, untypical courses occur.

Catarrhal stage (prodromal stage)

After an incubation period of 7 to 14 days, flu-like symptoms occur with a slight fever, runny nose and dry, tickly cough. This takes about one to two weeks. The risk of infection is greatest at this stage.

Convulsive stage

It is only in the second stage that the typical staccato-like coughing attacks that start suddenly appear with the tongue out. The seizures conclude with a whooping ("recapitulation") when you inhale. Glassy phlegm is often gagged up during the attacks, and vomiting also occurs. The cough attacks can be very numerous, accumulate at night and can be triggered by external influences such as physical exertion. The convulsive stage lasts two to six weeks.

Stage decrementi

In the last stage, the number of coughing attacks slowly decreases, and ultimately they are also less severe. This phase lasts another three to six weeks. Without antibiotic therapy, it can be six to ten weeks.Because of the very long duration of the illness, whooping cough is sometimes also called the “100-day cough”. In some children it has been observed that at this stage they also react to insignificant stimuli with coughing fits ("whooping cough tic"). Occasionally, the cause is tuberculosis activated by whooping cough .

Atypical courses

In infants under six months of age, the convulsive stage does not yet progress with the typical coughing fits. Rather, the attacks can only express themselves in the form of respiratory arrests ( apneas ). Even in adolescents and adults, the disease is often not recognized clinically because they have no symptoms other than a dry cough.

Complications

The most common complications are pneumonia (15 to 20%) and otitis media caused by secondary infection with Haemophilus influenzae or pneumococci . Secondary infections can be recognized by a rise in fever and signs of inflammation in the blood. Also seizures are approximately two to four percent a not uncommon complication. After all, 0.5% of those affected develop a brain disease ( encephalopathy ), which often results in permanent damage. The exact reason for this has not yet been clarified. The strong cough can sometimes cause bleeding into the conjunctiva of the eyes and inguinal or umbilical hernias . One in 1000 patients dies of the disease, mostly young infants.

diagnosis

Typical is the unproductive cough that can last over three weeks. An important clue for the diagnosis are similar diseases in the patient's environment. The diagnosis is often only made in the convulsive stage on the basis of clinical suspicion .

In order to confirm the diagnosis, the pathogens can be detected from the secretion that is obtained from the nasopharynx using a swab. However, the Bordetella bacteria are very sensitive to dehydration and cold. This can limit the sensitivity ( sensitivity , hit rate) of the detection. The specificity of the test is 100%. This means that those who get a positive test result are actually infected, while conversely not all infected people necessarily get a positive test result (sensitivity). The cultivation of B. pertussis takes at least three days , that of B. parapertussis two days. A faster diagnosis can be achieved through the detection of pathogen-specific genetic material ( DNA ) with the aid of the polymerase chain reaction (PCR). PCR is a very sensitive detection method. It can be positive even with very few germs and also includes dead bacteria, for example after starting treatment with an antibiotic . However, it is more complex and expensive than cultivating the pathogen.

Specific antibodies against B. pertussis appear in the serum at the earliest when the convulsive stage begins . Therefore, a blood test is not suitable for early diagnosis. With whooping cough there are also typical changes in the blood count . The total number of white blood cells increases ( leukocytosis ); the proportion of lymphocytes increases particularly sharply (relative lymphocytosis ). These changes in the blood count also only occur in the convulsive stage in around 20 to 80% of patients .

Differential diagnosis

In addition to whooping cough, other illnesses can be associated with prolonged coughing. Symptoms like those in the catarrhal stage can be caused by any pathogen that infects the upper airways, such as rhinoviruses and parainfluenza viruses . Also RSV , adenoviruses , Moraxella catarrhalis, Mycoplasma pneumoniae and Chlamydia pneumoniae can cause pertussis-like syndrome. Chlamydia trachomatis is also a possible pathogen in infants . A number of other infectious and non-infectious differential diagnoses must always be considered in adolescents and adults with a chronic cough, which can lead to suspicion of whooping cough. These include tuberculosis , bronchial asthma , chronic obstructive pulmonary disease ( COPD ), foreign bodies in the airways and tumors .

Whooping cough in adults

Whooping cough in adults is often associated with nausea , gag reflex, and vomiting . The patients suffer from poor appetite and insomnia. However, fever and other symptoms of the disease, which often occur in children, are mostly absent in adult patients. Since adults often lack the “gasping for air” typical of children, many adults consider the problem to be just a “normal” cough associated with a cold and do not seek medical treatment. This can have fatal consequences, as the bacteria can then spread further in the body and complications are possible. In addition, the risk of infection from undetected patients is high.

Mechanism of Pathogenesis

The harmful effect of this bacterium is essentially caused by the pertussis exotoxin . The toxin is released by the bacterium in an inactive form, then binds to a cell membrane receptor and is absorbed into the body's own cells via endocytosis. The endosome is first transported by retrograde transport to the Golgi apparatus and from there to the endoplasmic reticulum . During this transport, the pertussis toxin is activated - presumably by GSH or ATP. Now it catalyzes the ribosylation of the ADP of the Gi protein and thereby inactivates it. This inactivation of an inhibitory protein leads to permanent stimulation of the adenylate cyclase, which catalyzes the second messenger cAMP from ATP. Since z. For example, if the release of insulin by the adrenergic α2 receptor is reduced, a pertussis infection leads to hypoglycemia.

therapy

Since the typical coughing attacks are mainly caused by the toxins formed by the bacteria, treatment with an antibiotic can only shorten or alleviate the course of the disease if it is already in the catarrhal stage (first to second week) or at least in the early convulsive stage (beginning of a cough ) is administered. Treatment with azithromycin (for 2 to 5 days) or clarithromycin (for 7 days) is the standard therapy ( erythromycin or cotrimoxazole can also be taken for 14 days). Since the contagiousness can persist up to 3 weeks after the start of the convulsive stage, antibiotic therapy is also useful up to this point in time, as antibiotic therapy shortens the duration of the contagiousness to around 5 days after the start of therapy. Secondary infections, such as pneumonia (pertussis pneumonia), may require appropriate treatment with other antibiotics (in the case of pneumonia, for example, intravenous administration of cefotaxime or ceftriaxone over two weeks). The frequency and severity of coughing attacks can possibly be positively influenced by the use of steroids or substances that stimulate the sympathetic nervous system ( sympathomimetics ). However, the dosage, duration and type of application have not been reliably clarified. Important general measures include a low-irritation environment, plenty of fluids, and frequent small meals.

Amoxicillin and ampicillin- containing drugs for oral use are no longer recommended for the treatment of whooping cough in the current guidelines. The Federal Institute for Drugs and Medical Devices has asked the pharmaceutical companies concerned to delete the areas of application whooping cough / pertussis in the product information of their amoxicillin and ampicillin-containing drugs.

prevention

Vaccinations

The primary prophylaxis is effective (protection rate 80 to 90%) and well-tolerated vaccines . Today acellular pertussis vaccines (AP vaccines) are used, which are better tolerated than the whole-germ vaccines (wP vaccines) that were used in the past. They no longer contain the entire germ, but only those components of the pathogen that trigger an immune response in the body of the vaccinated person. The Standing Vaccination Commission (STIKO) at the Robert Koch Institute recommends three vaccinations in the first year of life, beginning in the ninth week of life, and a booster between the 12th and 15th month of life (basic immunization). In addition, children between the ages of five and six and adolescents between the ages of 9 and 18 should routinely receive a booster against whooping cough. If they were not vaccinated or not sufficiently vaccinated in childhood, the basic vaccination should also be made up for. Adults should generally receive a single vaccination against whooping cough. Seronegative women who want to have children in particular should be vaccinated before the start of pregnancy. There is already a pregnancy, the mother should as soon as possible to get vaccinated after birth: In March 2020, the vaccination is independent of the distance to previously administered pertussis vaccinations at the beginning of the third trimester recommended at elevated probability of premature birth already in 2nd trimester. The vaccination status of all household members such as father or partner, siblings, grandparents, etc. should also be checked and updated if necessary.

Since autumn 2009, the STIKO has recommended that all adults receive a one-off combination vaccination with the vaccine against pertussis when the next due tetanus / diphtheria vaccination (Td vaccination) is due . A Tdap combination vaccination can also be given if a previous Td-containing vaccination was less than five years ago. A single pertussis vaccine is currently not available since the last one (PAC MÉRIEUX by Sanofi Aventis ) was withdrawn from the market in 2005.

As vaccination reactions painful swelling and redness may occur at the injection site as well as increasing the temperature within one to three days of normal discussion of the body with the vaccine. Flu-like symptoms or gastrointestinal complaints are occasional. Adults occasionally have sore muscles and muscle swelling after vaccination . Hypersensitivity reactions are very rare. Other side effects such as cramps, which can accompany the fever that may occur, are rare and have no consequences. Antipyretic drugs can significantly reduce these side effects in children who are prone to feverish reactions. Since the introduction of acellular vaccines, the number of vaccinations against whooping cough has increased, but is still not sufficient. As there is currently no monovalent vaccine, vaccination is only possible with combination vaccines ; therefore combined against pertussis, tetanus (tetanus), diphtheria and optionally against polio vaccination.

A passive immunization with antibodies against pertussis bacteria for the protection of people who contact with sick had, has not proven to be effective and is no longer on the market. The vaccination does not guarantee complete immunity, you can get whooping cough despite being vaccinated, but the risk of getting sick is greatly reduced for vaccinated people compared to unvaccinated people.

Up until now it was assumed that the protection against recurrence of the disease would last about ten years after vaccination. This also led to corresponding recommendations that z. B. Women of childbearing age and close contacts with infants should only be vaccinated against whooping cough if no vaccination has taken place in the previous ten years. However, recent studies have shown that immunity does not last as long as expected after vaccination. After infection, protection against recurrence is assumed to last for four to 20 years; after vaccination, protection lasts for four to twelve years.

Chemoprophylaxis

After close contact between people who are susceptible to whooping cough and who have not been vaccinated against whooping cough (as well as high-risk patients with heart defects, patients with respiratory diseases and mucosal viscidosis patients as well as vaccinated people who have contact with people at risk) with infectious whooping cough patients, antibiotic treatment of these close contact persons is the same (with clarithromycin for seven days) as useful for illness to prevent the onset of the illness. If the contact is questionable or only fleeting, close observation is sufficient. If cough symptoms occur, an examination for whooping cough pathogens and antibiotic treatment should be initiated immediately.

Duration of contagion, isolation

Patients are still contagious about five days after starting antibiotic therapy and should be isolated for this period. Without appropriate treatment, the contagion remains for up to three weeks after the onset of the convulsive stage . This is why such patients are not allowed to visit community facilities again until three weeks after the onset of the illness at the earliest. Before they are allowed to do this again, it can be required that a pathogen detection is checked to determine whether the sick are still infectious.

history

First descriptions of whooping cough are ascribed to the French physician Guillaume de Baillou and date from the 16th century, but there are older ascriptions for England. He distinguished the tussis quinta (Latin fifth cough ) from croup coughing, among other things . A century later, among other English doctors, the famous physician Thomas Sydenham dealt with whooping cough under the name pertussis . Only in the context of major epidemics in the 18th century was whooping cough defined as an independent clinical picture. A devastating whooping cough epidemic occurred in Germany in 1815/1816. A century of purely clinical descriptions followed, until finally, in 1906, the Belgian bacteriologist Jules Bordet, together with his colleague Octave Gengou , was able to isolate the whooping cough pathogen later named after him. In doing so, they paved the way for a vaccination that was first introduced in 1933.

Reporting requirement

Whooping cough is a notifiable disease in Germany according to Section 6 (1) of the Infection Protection Act (IfSG). There is an obligation to report in the event of suspicion, illness or death. Proof of the pathogens Bordetella pertussis and Bordetella parapertussis must also be reported by name in accordance with Section 7 (1) IfSG. In the first case, the diagnosing doctor is required to report, in the second case the laboratory managers, etc. ( Section 8 IfSG).

In Austria it is a notifiable illness according to Section 1 (1) No. 2 of the 1950 Epidemic Act . Cases of illness and death must be reported. Doctors and laboratories, among others, are obliged to report this ( Section 3 Epidemics Act).

literature

  • JG Liese: Pertussis. In: Infectiology Manual of the DPGI. 5th edition. 2009.
  • Karl Wurm, AM Walter: Infectious Diseases. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition ibid 1961, pp. 9-223, here: pp. 110-117 ( whooping cough ).

Web links

Commons : Whooping Cough  - Collection of pictures, videos, and audio files
Wiktionary: Whooping cough  - explanations of meanings, word origins, synonyms, translations

Individual evidence

  1. ↑ Missing vaccination protection whooping cough wave recorded Germany , on spiegel.de, accessed on May 28, 2018
  2. ↑ a b c d e f g h i j k l German Society for Pediatric Infectious Diseases . V. (DGPI) (Ed.): Handbook infections in children and adolescents. 4th edition. Futuramed, Munich 2003, ISBN 3-923599-90-0 . (6th edition 2013)
  3. ↑ RW Steele: Pertussis is eradication achievable? In: Pediatric Annals (2004) 33 (8), pp. 525-534, PMID 15354604
  4. ↑ WHO position paper, PDF  ( page no longer available , search in web archives )  Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice.@1@ 2Template: Dead Link / www.who.int  
  5. ^ Robert Koch Institute: Epidemiological Bulletin . 2005; 23, pp. 195-198.
  6. ↑ Pertussis increased in adults (Doctors newspaper)
  7. ↑ Berthold Koletzko (Ed.): Pediatric and Adolescent Medicine . 14th edition. Springer-Verlag, 2013, ISBN 978-3-642-11379-6 , pp. 225 ( google.com ).
  8. ↑ Berthold Koletzko (ed.): Von Harnack Pediatrics . 11th edition. Springer-Verlag, 2013, ISBN 978-3-662-22597-4 , pp. 269 ( google.com ).
  9. ^ Ulrich Heininger: Pertussis in adolescents and adults . Georg Thieme Verlag, 2003, ISBN 978-3-13-132831-1 , p. 12.
  10. ↑ Whooping cough
  11. ^ Plaut RD, Carbonetti NH (May 2008). "Retrograde transport of pertussis toxin in the mammalian cell". Cell. Microbiol. 10 (5): pp. 1130-1139. doi : 10.1111 / j.1462-5822.2007.01115.x . PMID 18201245 .
  12. ^ Carbonetti NH (2010). "Pertussis toxin and adenylate cyclase toxin: key virulence factors of Bordetella pertussis and cell biology tools". Future Microbiol 5 (3): pp. 455-469. doi : 10.2217 / fmb.09.133 . PMC 2851156 (free full text). PMID 20210554 .
  13. ^ Marianne Abele-Horn: Antimicrobial Therapy. Decision support for the treatment and prophylaxis of infectious diseases. With the collaboration of Werner Heinz, Hartwig Klinker, Johann Schurz and August Stich, 2nd, revised and expanded edition. Peter Wiehl, Marburg 2009, ISBN 978-3-927219-14-4 , p. 205.
  14. ↑ Marianne Abele-Horn (2009), p. 205.
  15. ↑ a b c Pertussis (whooping cough): RKI advice for doctors
  16. ↑ A. Thiele: Amoxicillin and ampicillin-containing drugs: deletion of the areas of application whooping cough / pertussis. (PDF; 52.4 kB) Defense against dangers from drugs. Federal Institute for Drugs and Medical Devices (BfArM), August 14, 2013, accessed on May 7, 2015 .
  17. ↑ a b Website of the Robert Koch Institute: FAQ on pertussis
  18. ↑ Epidemiological Bulletin 3/2006, PDF
  19. ↑ Last monovalent pertussis vaccine from the Arznei-Telegram market of July 2005.
  20. ^ Robert Koch Institute: Recommendations of the Standing Vaccination Commission (STIKO) at the Robert Koch Institute / as of June 2012. In: Epidemiologisches Bulletin. July 30, 2012 / No. 30, pp. 283-310, ISSN  1430-0265 ( PDF; 188 kB )
  21. ↑ Maxwell A. Witt et al. : Unexpectedly limited durability of immunity following acellular pertussis vaccination in preadolescents in a North American outbreak. In: Clinical Infectious Diseases . Volume 54, 2012, pp. 1730-1735, PMID 22423127 , ISSN  1058-4838
  22. ↑ Aaron M. Wendelboe et al. : Duration of Immunity Against Pertussis After Natural Infection or Vaccination. In: The Pediatric Infectious Disease Journal . Volume 24, 2005, pp. S58-S61, PMID 15876927 , ISSN  0891-3668
  23. ↑ Marianne Abele-Horn (2009), p. 205.
  24. ↑ FGA Versteegh, JFP Schellekens, A. Fleer, JJ Roord: Pertussis: a concise historical review including diagnosis, incidence, clinical manifestations and the role of treatment and vaccination in management. In: Rev Med Microbiol. (2005); 16 (3), pp. 79-89.
  25. ↑ J.-Ch. Sournia, J. Poulet, M. Martiny (Ed.): Illustrated history of medicine . Digital library, volume 53.Directmedia, Berlin 2004.
This version was added to the list of articles worth reading on October 3, 2006 .