NM-341
Perioperative Pertussis in an Infant
Jahangiri M, Willer B, Blair N
University of Iowa, Iowa City, Iowa, United states
A 39 day old, 4.6 kg term infant male with 2 week history of worsening cough, difficulty feeding, and weight loss presented to the operating room for airway evaluation. His initial symptoms of congestion, coughing spells, and irritability were reported to the pediatrician 2 weeks prior. At that time, physical exam was unremarkable. Prior to admission and OR presentation, RSV testing, chest X-ray, swallow study, and esophagogastroduodenoscopy were unremarkable. During hospitalization he had up to 12 coughing spells daily lasting 60 seconds, leading to oxyhemoglobin desaturation to 70%. The patient underwent a smooth induction and was maintained with a Propofol infusion for direct laryngoscopy, bronchoscopy, and esophagoscopy to evaluate for potential tracheoesophageal fistula and laryngeal cleft. All studies revealed normal anatomy and the patient tolerated an uneventful general anesthetic. Post procedure, pertussis PCR was obtained and the patient was started on azithromycin for presumptive Bordetella pertussis infection. Patient’s symptoms showed progressive improvement and he was discharged on hospital day 5, with his pertussis PCR returning positive. Of note, the patient’s mother received a DTaP vaccine during pregnancy and his father had been previously immunized. The source of the pertussis exposure was never determined.
Bordetella pertussis infection is amongst the top 10 global causes of childhood mortality (1). Young infants are especially vulnerable to severe disease, where fulminant pertussis involves a rapidly progressive pneumonia that devolves into a necrotizing bronchiolitis (2). A secondary pulmonary hypertension may occur leading to refractory cardiac failure, often requiring ECMO (2).
Vaccination of infants against pertussis does not begin until 2 months of age; prior to the age where newborns can benefit from the vaccine, maternal antibodies transferred during pregnancy can provide protection for about 6 weeks (3). Since 2013, the Advisory Committee on Immunization Practices recommends DTaP (diphtheria toxoid, tetanus toxoid, acellular pertussis) vaccination in pregnant women, regardless of previous vaccine administration (3). Maternal DTaP vaccination during pregnancy is up to 91% protective against infant pertussis (3).
With increasing vaccine hesitancy, healthcare providers may face infectious diseases not commonly encountered during training. Given the absence of the classic paryoxysmal cough or inspiratory whoop in infants, anesthesiologists should maintain a high index of suspicion and consider pertussis in their differential during the preoperative anesthetic evaluation. Although this patient had an uneventful anesthetic and airway investigation, the effect of anesthesia on disease progression is unknown.
Paddock, C. et al. Pathology and Pathogenesis of Fatal Bordetella pertussis Infection in Infants, Clinical Infectious Diseases, Volume 47, Issue 3, 1 August 2008, Pages 328–338.
Sawal, M. et al. Fulminant pertussis: A Multi-Center Study with New Insights into the Clinico-Pathological Mechanisms. Pediatric Pulmonology 2009, 44: 970–980.
Baxter, R. et al. Effectiveness of Vaccination During Pregnancy to Prevent Infant Pertussis. Pediatrics 2017 May; 139:e20164091.
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