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Pertussis Encephalopathy in an Adult: Case Report and Review Scott A. Halperin and Thomas J. Marrie

From the Departments of Pediatrics, Medicine, and Microbiology, Dalhousie University, Halifax, Nova Scotia, Canada

A 39-year-old man developed paroxysmal cough, occasional vomiting after cough, and subconjunctival hemorrhage. His illness was complicated by episodes of seizure, with clonic movements ofthe arms and legs, briefloss of consciousness, and confusion. The episodes were triggered by mild, unremarkable coughing paroxysms. A diagnosis of pertussis was confirmed serologically by measurement ofIgG, IgA, and IgM antibodies to pertussis toxin and filamentous hemagglutinin. Serologicstudies confirmed the presence of Bordetella pertussis infection in the patient's to-year-old daughter and suggested that his wife was infected as well. This case report illustrates the occurrence of typical pertussis with serious complications in an adult. Further research is required to determine the scope of this problem and the need for a program of adult immunization against pertussis.

Case Report Description. A 39-year-old man presented after two episodes of loss of consciousness, each of which lasted for 20 seconds and was associated with shaking of the arms and legs. Three weeks before admission he had developed a dry, nonproductive cough. Over the next 2 weeks, the cough became more frequent and paroxysmal and was associated with facial erythema and occasional vomiting. The patient complained of retrosternal muscular tightness, the sensation of a foreign body in his throat, hoarseness, and dysphagia. His wife observed that after coughing paroxysms he was transiently short of breath and confused. He developed bilateral subconjunctival hemorrhages and a strained muscle of the back from

Received 17 August 1990; revised 26 December 1990. Grant support: Health and Welfare Canada (National Health Research and Development grants 6603-1244-54 and 6603-1245-54). Reprints and correspondence: Dr. Scott A. Halperin, I.W.K. Children's Hospital, 5850 University Avenue, Halifax, Nova Scotia, Canada B3J 309. Reviews of Infectious Diseases 1991;13:1043-7 © 1991 by The University of Chicago. All rights reserved. 0162-0886/91/1306-0026$02.00

coughing. Treatment with amoxicillin and a cough suppressant for bronchitis gave no relief. The patient had no fever, chills, or hemoptysis. His 10-year-olddaughter had had a similar illness beginning 3 days before his illness, but her condition had resolved. On the day of admission, the patient experienced a single, brief episode of coughing and then lost consciousness. His eyes deviated upward and to the right, and he had clonic movements of both arms and legs lasting for 20 seconds. He regained consciousness rapidly but was confused and disoriented for the next minute. There was no bowel or bladder incontinence. After a second, similar episode, he was admitted to the hospital. The patient's medical history included recurrent otitis media as an adolescent and a peritonsillar abscess requiring tonsillectomy 6 months before admission. There was a history of migraine but none of seizures, hypertension, or cardiovascular disease. He did not know his immunization status. The patient's blood pressure was 120/80mm Hg; his heart rate, 90; and his respiratory rate, 22. He had a large left subconjunctival hemorrhage. His face was flushed, and pharyngeal erythema was evident. The cardiac examination was normal. Examination of the chest demonstrated a prolonged expiratory phase with coarse rhonchi and no rales or wheezes. Deep inspiration induced paroxysms of ru15 coughs that were not followed by a "whoop." On neurologic examination the patient was alert and oriented. He had normal muscular tone and strength and a normal sensory examination. Deep tendon reflexes were normal and symmetric. Laboratory data included a white blood cell count of 10.6 x 109/L, with 79% neutrophils, 1% bands, 16% lymphocytes, and 4 % monocytes. The hemoglobin level was 152 g/L, and the platelet count was 319 x 109/L. The following values were normal: serum electrolytes, creatinine, calcium, and phosphate; blood urea nitrogen and glucose; and hepatic enzymes. An arterial blood gas measurement performed while the patient was breathing room air showed a pH of 7.40, a partial pressure of carbon dioxide of 41 mm Hg, a partial pres-

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Although considered to be a disease that primarily affects children, pertussis can occur in adults [1]. Some investigators have hypothesized that adults generally have asymptomatic, mild, or atypical infections and are the source of spread of Bordetella pertussis to susceptible infants [1, 2]. Other researchers have argued that most adults with pertussis have characteristic symptoms [3, 4] that are inappropriately attributed to other causes because of the mistaken belief that whooping cough does not occur in adults [1, 5]. Most morbidity and mortality associated with pertussis affect young children, particularly those 2 SD above the mean values for control sera [7]. In the second specimen, which was taken 3 weeks later, there was a significant fall in the titers of IgA antibody to PT and IgM antibody to FHA. IgG antibodies to PT and FHA were present in both serum specimens. The patient's daughter had serologic evidence of pertussis in the first serum specimen, with titers of IgM and IgA antibody to PT and FHA

Table 1. Titers of antibody to PT and FHA measured by ELISA in serum from a patient with pertussis encephalopathy and from the members of his family. Antibody titer* PT Serum source t Negative controls'[ Mean Mean + 2 SD Patient Acute Convalescent Wife Acute Convalescent Daughter Acute Convalescent Son Acute Convalescent

FHA

IgG

IgA

IgM

IgG

IgA

IgM

ND§ ND

12 28

14 38

ND ND

104 607

27 140

2,467 2,280

244 28

57 56

820 771

5,206 1,506

297

Pertussis encephalopathy in an adult: case report and review.

A 39-year-old man developed paroxysmal cough, occasional vomiting after cough, and subconjunctival hemorrhage. His illness was complicated by episodes...
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