Pertussis natural history, complications and prognosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yazan Daaboul, M.D.; Serge Korjian M.D.; Aditya Govindavarjhulla, M.B.B.S. [2]; Rim Halaby, M.D. [3]

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Overview

The clinical course of the illness is divided into three stages: catarrhal, paroxysmal and convalescent. If left untreated, the majority of patients with clinical manifestations of pertussis develop low-grade fever and coryza (runny nose, occasional cough) for 1-2 weeks, followed by paroxysmal fits of whooping cough that may last 1-6 weeks, before finally recovering from the disease. Compared with children, adolescents and adults usually experience a milder course of the disease, and the characteristic whooping cough may be absent. Unvaccinated or incompletely vaccinated infants younger than 12 months of age have the highest risk for developing severe infection and life-threatening complications and death. Complications of pertussis include apnea, pneumonia, seizure, and death. Prognosis is generally excellent, but unvaccinated or incompletely vaccinated infants younger than 12 months of age have the highest risk for severe and life-threatening complications and death.

Natural History

• The clinical course of the illness is divided into three stages: catarrhal, paroxysmal and convalescent.
• Pertussis has an insidious onset with catarrhal symptoms that are indistinguishable from those of minor respiratory tract infections.
• The cough, which is initially intermittent, becomes paroxysmal. In typical cases paroxysms terminate with inspiratory whoop and may be followed by post-tussive vomiting. Paroxysms of cough, which may occur more at night, usually increase in frequency and severity as the illness progresses and typically persist for 2 to 6 weeks or more.
• The illness can be milder and the characteristic "whoop" may be absent in children, adolescents and adults who were previously vaccinated. After paroxysms subside, a nonparoxysmal cough can continue for 2 to 6 weeks or longer.
• Unvaccinated or incompletely vaccinated infants younger than 12 months of age have the highest risk for developing severe infection and life-threatening complications and death.

Shown below is a table summarizing the main clinical findings in each stage.

Natural History of Pertussis

Stage	Duration	Key features
Catarrhal	Usually 7-10 days; range of 4-21	- Low grade fever - Coryza - Mild occasional cough
Paroxysmal	Usually lasts 1-6 weeks, but may persist for up to 10 weeks	- Paroxysms of numerous, rapid coughs due to difficulty expelling thick mucus from the tracheobronchial tree - Long aspiratory effort accompanied by a high-pitched "whoop" at the end of the paroxysms - Cyanosis - Vomiting and exhaustion - Paroxysmal attacks occur frequently at night, with an average of 15 attacks per 24 hours - Paroxysmal attacks increase in frequency during the first 1-2 weeks, remain at the same frequency for 2-3 weeks, and then gradually decrease
Convalescent	Usually 7-10 days; range of 4-21	- Gradual recovery - Less persistent, paroxysmal coughs that disappear in 2-3 weeks - Paroxysms often recur with subsequent respiratory infections for many months after the onset of pertussis

^{Timeline of pertussis clinical manifestations. Retrieved from Centers of Disease Control and Prevention (CDC)}

Complications

Pertussis may cause serious and potentially life-threatening complications, especially among infants and young children. Patients who are not fully vaccinated are more predisposed to developing pertussis-related complications.

• Sleep apnea (most common)
• Epistaxis
• Pneumonia
• Otitis media
• Pneumothorax
• Refractory pulmonary hypertension
• Urinary incontinence
• Hernia
• Rectal prolapse
• Rib fracture
• Seizures
• Subdural hematoma
• Encephalopathy

Prognosis

• Unvaccinated or incompletely vaccinated infants younger than 12 months of age have the highest risk for severe and life-threatening complications and death.
• Treatment with an effective antimicrobial agent the infectious period but does not generally alter the outcome of the disease.
• When treatment is initiated during the catarrhal stage, symptoms may be less severe.
• Among adolescents and adults, pertussis is generally less severe, and the characteristic whooping cough is less frequently described.