NYU Medical Grand Rounds Clinical Vignette

Christopher Schultz, MD, PGY-2

February 24, 2010

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

A 53-year-old man presents with fever, cough and malaise for ten days.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient was in his usual state of good health until three weeks prior to presentation, when he was reunited with his 11-year-old son who had been away at camp.

• The son had returned home with malaise and a non-productive paroxysmal cough associated with vomiting.

• The boy’s illness persisted for one week and resolved without treatment.

• The child had no fever throughout his illness and was reported to have received all routine age-appropriate childhood vaccinations.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• One week prior to presentation, the patient began to experience malaise and cough.

• Over the next four days, the patient’s condition did not improve, and he began experiencing fever, head ache and chest pain in addition to his original symptoms.

• He presented for further evaluation.

Additional History

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Past Medical History• None• Unknown vaccinations

Past Surgical History• None

Family History• Mother: diabetes mellitus

Social History• Born in Bermuda• Divorced• Lives with son • One bedroom apartment• Lifetime non-smoker• Social alcohol use• Denies illicit drug use

Outpatient Medications

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

None

Allergies: None

Physical Examination

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

General: Well-appearing man in no acute distress, experiencing occasional cough

Vitals: T 100.7, BP 125/85, HR 85, RR 14

O2 saturation: 98% on room air

The remainder of the physical exam was normal.

Initial Studies

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• CBC:

• White blood cell count 16,000

• Lymphocytic predominance

• The remainder was within normal limits

• Basic Metabolic Panel: Within normal limits

• Hepatic Panel: Within normal limits

Imaging

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Chest X-Ray

• Mild bilateral basilar atelectasis

• No consolidation or effusions noted

Initial Studies

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Sputum Gram Stain:

• Large numbers of polymorphonuclear leukocytes• Some gram-negative coccobacilli.

Sputum culture was collected.

Working diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Bronchitis

Clinical Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient was prescribed ampicillin-clavulanic acid, but his symptoms persisted.

• Growth from the patient’s sputum culture was consistent with a normal respiratory biota.

• Two weeks into the patient’s illness, he developed paroxysmal coughing with occasional vomiting.

• These paroxysms increased over several weeks, and persisted for over one month.

Clinical Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• During his prolonged clinical course, the patient underwent additional serologic testing at a follow-up visit.

• IgG and IgA antibody titers to filamentous hemagglutinin and pertussis toxin were obtained and markedly elevated.

• Two weeks later, the patient’s coughing paroxysms finally resolved.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Final Diagnosis

Acute Bordetella pertussis infection transmitted through a previously immunized

child presenting with atypical disease

Case report modified from: Smith S and RC Tilton. Journal of Clinical Microbiology 1996; 34: 429-30.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

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