Paediatrica Indonesiana

January

VOLUME 52

NUMBER 1

Original Article

Pertussis-like syndrome or pertussis: a delay diagnosis

Heda Melinda Nataprawira, Finia Cahayasari, Arifin Kashmir

Abstract
Background Recent reports of pertussis epidemiology from Asia,
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WKH KLJKHVW GLVHDVH EXUGHQ 'LIILFXOW\ LQ HVWLPDWLQJ WKH SUHYDOHQFH
of pertussis is due to lack of access to diagnostic methods,
misdiagnoses, under-reporting, and different countries reporting
FULWHULD $ V\QGURPH FKDUDFWHUL]HG E\ VHYHUH HSLVRGHV RI FRXJKLQJ
resembling whooping cough (pertussis) has also been defined as
pertussis-like syndrome.
Objective 7R UHSRUW HOHYHQ FDVHV RI SHUWXVVLV RU SHUWXVVLV OLNH
syndrome in the pediatric ward of Hasan Sadikin Hospital.
Methods 7KLV UHWURVSHFWLYH VWXG\ ZDV FRQGXFWHG E\ UHYLHZLQJ
PHGLFDO UHFRUGV IURP

&KDUDFWHULVWLFV RI SHUWXVVLV
like syndrome patients were documented including age, gender,
history of pertussis immunization, clinical manifestations,
laboratory findings, initial diagnosis, treatment and clinical
response. Isolation of Bordetella pertussis XVLQJ %RUGHW *HQJRX
DJDU ZDV DOVR QRWHG 3HUWXVVLV GLDJQRVHV ZHUH JURXSHG EDVHG RQ
two classifications: probable and confirmed.
Results (OHYHQ SDWLHQWV ZHUH GLDJQRVHG ZLWK SHUWXVVLV OLNH
syndrome, including 5 boys and 6 girls. Most subjects were less
WKDQ PRQWKV RI DJH 2QO\ RQH VXEMHFW KDG UHFHLYHG SUHYLRXV
SHUWXVVLV LPPXQL]DWLRQ '\VSQHD SDUR[\VPDO FRXJK DQG IHYHU
were the most common symptoms. All were initially diagnosed
WR KDYH KDG VHYHUH EDFWHULDO SQHXPRQLD DQG ODWHU FKDQJHG WR
SUREDEOH SHUWXVVLV 7KUHH VXEMHFWV H[KLELWHG SRVW WXVVLYH YRPLWLQJ
and cyanosis, while none had apneic symptoms. All B. pertussis
LVRODWLRQV \LHOGHG QHJDWLYH UHVXOWV $PSLFLOOLQ RU FHSKDORVSRULQ
ZDV LQLWLDOO\ DGPLQLVWHUHG 3DWLHQWV UHFHLYLQJ VXEVHTXHQW
clarithromycin showed good clinical responses.
Conclusion $OO LQIDQWV ZHUH OLNHO\ FRQVLGHUHG WR KDYH SHUWXVVLV
DV PRVW KDG QR SHUWXVVLV LPPXQL]DWLRQV +RZHYHU B. pertussis
isolation was unsuccessful in all cases. As such, diagnoses could
not be confirmed. [Paediatr Indones. 2012;52:28-31].
Keywords: Pertussis, pertussis-like syndrome,
Bordet-Gengou agar, clarithromycin

28 Paediatr Indones, Vol. 52, No. 1, January 2012

ertussis, also known as whooping cough, is a

highly contagious respiratory tract infection,
DIIHFWLQJ DQ HVWLPDWHG PLOOLRQ SHRSOH \HDUO\
DQG FDXVLQJ QHDUO\
GHDWKV LQ FKLOGUHQ
yearly. Though recent reports of pertussis epidemiology
from Asia, Africa and South America are limited, the
World Health Organization (WHO) estimates that
FRXQWULHV LQ WKHVH UHJLRQV LQFOXGLQJ ,QGRQHVLD KDYH
the highest disease burden.1 (VWLPDWLQJ SUHYDOHQFH
of pertussis is difficult due to the lack of access to
diagnostic methods, misdiagnoses, under-reporting,
and different reporting criteria between countries.
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UHSRUWHG HYHQ LQ FRXQWULHV ZLWK KLJK YDFFLQDWLRQ
FRYHUDJH DQG DWWULEXWHG WR YDULRXV IDFWRUV LQFOXGLQJ
LQFUHDVHG DZDUHQHVV LPSURYHG GLDJQRVWLFV GHFUHDVHG
YDFFLQDWLRQ FRYHUDJH VXERSWLPDO YDFFLQHV ZDQLQJ
YDFFLQH LQGXFHG LPPXQLW\ DQG SDWKRJHQ DGDSWDWLRQ
7KH UHODWLYH FRQWULEXWLRQ RI WKHVH IDFWRUV PD\ GLIIHU
between countries and is the subject of ongoing
debate.2

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( PDLO heda_1155@yahoo.com

Paediatr Indones, Vol. 52, No. 1, January 2012 28

Heda Melinda Nataprawira et al: 3HUWXVVLV OLNH V\QGURPH RU SHUWXVVLV D GHOD\ GLDJQRVLV

Bordetella pertussis D *UDP QHJDWLYH FRFFREDFLOOXV

was reported as a major etiologic agent of prolonged
FRXJK GXULQJ FKLOGKRRG LQ XQYDFFLQDWHG SRSXODWLRQV
Classic whooping cough is characterized by three distinct
VRPHWLPHV UHVHPEOLQJ D FROG RU RWKHU YLUDO LOOQHVV
DQG ODVWLQJ ZHHNV )ROORZLQJ WKLV LQLWLDO FDWDUUKDO
stage, coughing becomes predominant, continuing
to the paroxysmal stage, in which patients exhibit a
ZKRRS VRXQG RQ LQVSLUDWLRQ VRPHWLPHV IROORZHG
E\ YRPLWLQJ 7KLV VWDJH ODVWV EHWZHHQ ZHHNV 7KH
ILQDO FRQYDOHVFHQW VWDJH PD\ SHUVLVW IRU PDQ\ ZHHNV
DQG LQYROYH FRXJKLQJ HSLVRGHV RI UHGXFHG VHYHULW\
Whooping cough is most contagious during the 2-week
FDWDUUKDO VWDJH YLD UHVSLUDWRU\ GURSOHWV 8QIRUWXQDWHO\
diagnosis is often not made until the paroxysmal stage,
when the characteristic cough occurs.1,4 To date, it is
difficult to confirm pertussis, resulting in late diagnoses
of pertussis or pertussis-like syndrome. In most cases,
a working diagnosis has to be made on strong clinical
suspicion. In order to assess the adequacy of clinical
DQG LQYHVWLJDWLRQDO GDWD LQ WKH GLDJQRVLV RI SHUWXVVLV RU
pertussis-like syndrome, we report the clinical profiles
and treatment responses in 11 subjects with pertussis or
pertussis-like syndrome.

Methods
All pediatric inpatients in Hasan Sadikin Hospital
GLDJQRVHG DV KDYLQJ SHUWXVVLV RU SHUWXVVLV OLNH
V\QGURPH IURP -DQXDU\
'HFHPEHU
ZHUH
LQFOXGHG LQ RXU VWXG\ 'DWD ZDV UHWULHYHG IURP KRVSLWDO
medical records and our own pertussis or pertussis-like
syndrome registry.
$FFRUGLQJ WR
&HQWHUV RI 'LVHDVH &RQWURO
&'& 6 which was reformatted for clarification in
the diagnosis of pertussis was based on two
case classifications: (1) probable, a case that meets
WKH FOLQLFDO FDVH GHILQLWLRQ D FRXJK LOOQHVV ODVWLQJ
weeks with at least one of the following: paroxysms
RI FRXJKLQJ LQVSLUDWRU\ ZKRRS RU SRVWWXVVLYH
YRPLWLQJ ZLWKRXW RWKHU DSSDUHQW FDXVH DV UHSRUWHG
by a health professional), is not laboratory confirmed,
and is not epidemiologically linked to a laboratoryconfirmed case; and (2) confirmed, a case of acute
cough illness of any duration with isolation of B.
pertussis from a clinical specimen, or a case that meets

29 Paediatr Indones, Vol. 52, No. 1, January 2012

Table 1. Characteristics of subjects

Subjects characteristics

n=11

Gender, n
Male

Age distribution, n
0-1 months
1-6 months
6-12 months
Symptoms present
Cough, n
Average length of cough, days
Fever, n
Dyspnea, n
Average length of dyspnea, days
Cyanosis, n
Vomiting, n
.CDQTCVQT[ PFKPIU
Lymphocytosis due to leukocytosis, n
Bordet Gengou cultures
Positive, n
Negative, n
%CUG FGPKVKQPU
Probable, n
%QPTOGF P
Previous DTP immunization, n
Macrolide (clarithromycin) treatment

1
9
1
11
10.5
9
9
2
3
3

5
0
10
11
0
1
11

the clinical case definition and is confirmed by either

FXOWXUH RU 3&5
5HFRUGV ZHUH UHYLHZHG LQ GHWDLO ZLWK UHJDUGV WR
age, gender, history of pertussis immunization, clinical
manifestations, laboratory findings, initial diagnosis,
treatment and clinical response to therapy. B. pertussis
LVRODWLRQ FXOWXUHV XVLQJ %RUGHW *HQJRX DJDU ZHUH
performed in the Bio Farma Laboratory (Bandung,
Indonesia).

Results
Of all of pediatric inpatients admitted during
WKH VSHFLILHG SHULRG
ZHUH IRXQG WR KDYH EHHQ
GLDJQRVHG DV KDYLQJ SHUWXVVLV RU SHUWXVVLV OLNH
syndrome. Subjects ages ranged from 1 to 12
PRQWKV ZLWK PRVW VXEMHFWV LQ WKH PRQWK ROG
age group. Male to female ratio was similar. The
leading symptoms at presentation were dyspnea and
FRXJK 2QO\ SDWLHQWV SUHVHQWHG ZLWK F\DQRVLV DQG
YRPLWLQJ 1RQH UHSRUWHG DSQHLF V\PSWRPV 0HDQ
duration of symptoms before coming to the hospital

Paediatr Indones, Vol. 52, No. 1, January 2012 29

Heda Melinda Nataprawira et al: 3HUWXVVLV OLNH V\QGURPH RU SHUWXVVLV D GHOD\ GLDJQRVLV

ZDV
GD\V DQG WKH DYHUDJH WLPH IRU GLDJQRVLV DQG
initiation of macrolide antibiotic treatment in the
ward after the initial hospital presentation was 4 days.
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Leukocytosis with absolute lymphocytosis was
REVHUYHG LQ
SDWLHQWV %RUGHW *HQJRX DJDU
FXOWXUHV ZHUH SHUIRUPHG IRU SDWLHQWV EXW DOO WHVWV
\LHOGHG QHJDWLYH UHVXOWV %DVHG RQ WKH WZR SHUWXVVLV
classifications (probable and confirmed), all 11
SDWLHQWV ZHUH WKRXJKW WR KDYH SUREDEOH SHUWXVVLV $OO
SDWLHQWV ZHUH LQLWLDOO\ GLDJQRVHG DV KDYLQJ VXVSHFWHG
VHYHUH EDFWHULDO SQHXPRQLD EXW ZHUH ODWHU GLDJQRVHG
DV KDYLQJ SUREDEOH SHUWXVVLV 7KHUHIRUH DPSLFLOOLQ
RU FHSKDORVSRULQ ZHUH LQLWLDOO\ JLYHQ IRU WUHDWLQJ
VHYHUH EDFWHULDO SQHXPRQLD &ODULWKURP\FLQ ZDV
JLYHQ RQ WKH VHFRQG ZHHN RI LQLWLDO V\PSWRPV DQG
after probable pertussis or pertussis-like syndrome
was diagnosed. 8 3DWLHQWV VKRZHG JRRG FOLQLFDO
response.

Discussion
We only documented 11 patients with pertussis-like
syndrome in the study period from Hasan Sadikin
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3URYLQFH 0RVW VXEMHFWV ZHUH LQIDQWV ZKLFK ZDV WKH
highest burden in the unimmunised age groups. 1
Although pertussis could not be confirmed, we
assumed that all patients had probable pertussis.
'\VSQHD SDUR[\VPDO FRXJK DQG IHYHU ZHUH SUHVHQW
LQ DOPRVW DOO LQIDQWV *HQHUDOO\ IHYHU LV ORZ JUDGH
throughout the course of illness.4
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cyanosis while none reported apneic symptoms.
Classic whooping cough is characterized by three
distinct stages of illness where initial symptoms are
non-specific, sometimes resembling a cold or other
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the initial catarrhal stage, the cough becomes
predominant. Continuing to the paroxysmal stage,
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VRPHWLPHV IROORZHG E\ YRPLWLQJ 7KLV VWDJH W\SLFDOO\
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and hard whooping, partial whooping, or no whooping,
which makes it difficult for clinicians to identify the
disease. Whooping cough is most contagious during
WKH ZHHN FDWDUUKDO VWDJH YLD UHVSLUDWRU\ GURSOHWV

30 Paediatr Indones, Vol. 52, No. 1, January 2012

Unfortunately, the diagnosis is often not made until

the paroxysmal stage, when the characteristic cough
occurs.1,4 :H KDYH WR FRQVLGHU SHUWXVVLV LI SDUHQWV
report infants with cough and apneic symptoms, the
latter of which did not occur in our study. At the end
of the catarrhal phase, leukocytosis with an absolute
lymphocytosis frequently begins, reaching its peak at
the height of the paroxysmal stage. At this time, the
WRWDO EORRG OHXNRF\WH OHYHOV PD\ UHVHPEOH WKRVH RI
OHXNHPLD
P/ ZLWK
O\PSKRF\WHV
From our study we found only 5 infants with absolute
lymphocytosis.
7KH ILQDO FRQYDOHVFHQW VWDJH PD\ SHUVLVW IRU
weeks, and is characterized by a gradual decrease in
FRXJK EHIRUH WKH SDWLHQW UHWXUQV WR QRUPDO +RZHYHU
paroxysms often recur with subsequent respiratory
infections for many months after the onset of pertussis.
This situation might confuse the parents.
(YHQWKRXJK FXOWXULQJ B. pertussis is the gold
VWDQGDUG KRZHYHU LWV ODFN VHQVLWLYLW\ DQG PD\EH
compromised by prior antiobiotics treatment,
immunization status, duration of illness prior to
FXOWXUH VSHFLPHQ WUDQVSRUW WLPH JUHDWHU WKDQ
days), poor specimen quality and lack of expertise.
+RZHYHU WKH &'& 3HUWXVVLV /DERUDWRU\ UHFRPPHQG
a Regan-Lowe medium because of its superiority
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In our hospital the specimens must be sent to the
Bio Farma Laboratory located near the hospital, as
culturing cannot be done. Specimens are collected
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decreases sharply if the specimen is taken more
than 2 weeks after onset of cough. Three weeks
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LV RQO\
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and adolescents who are more likely to present late
in the course of illness.4 This reason may explain the
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'HOD\HG GLDJQRVLV W\SLFDOO\ RFFXUV GXULQJ
hospitalization during the paroxysmal stage when
patients present with dyspnea, not whooping
cough. Furthermore, from patient histories, other
classic symptoms of pertussis, especially those in
the catharral phase, are not fully recognized and
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ZHUH LQLWLDOO\ GLDJQRVHG DV VXVSHFWHG VHYHUH EDFWHULDO
pneumonia. Only later were the cases were diagnosed
DV SUREDEOH SHUWXVVLV EDVHG RQ SRVLWLYH FOLQLFDO FDVH

Paediatr Indones, Vol. 52, No. 1, January 2012 30

Heda Melinda Nataprawira et al: 3HUWXVVLV OLNH V\QGURPH RU SHUWXVVLV D GHOD\ GLDJQRVLV

definition, though none were laboratory confirmed,

nor epidemiologically linked to a laboratory-confirmed
case.
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Mycoplasma pneumoniae and Chlamydia pneumoniae.11
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of pertussis diagnosis.
In these cases, antibiotics such ampicillin or
FHSKDORVSRULQ ZHUH LQLWLDOO\ JLYHQ IRU WKH VHYHUH
bacterial pneumonia diagnosis. Clarithromycin, the
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initial symptoms to most infants. Clarithromycin
administration led to a good clinical response, mostly
by the third day after its commencement.
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of pertussis or pertussis-like syndrome occurred. At
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pneumonia, due to their chief complaint of dyspnea
and cough, since most came to the hospital after the
catarrhal phase was complete. Furthermore, the late
VWDJH KRVSLWDOL]DWLRQV PD\ KDYH FRQWULEXWHG WR WKH
QHJDWLYH FXOWXUHV DV LVRODWLRQ RI B.pertussis requires
precise timing of the specimen collection, thus leading
to difficulties in confirming the pertussis diagnosis. As
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LQ VSLWH RI WKH QHJDWLYH FXOWXUH UHVXOWV DV PRVW KDG
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increased toxin production associated with pertussis
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References

the control of pertussis outbreaks: National Immunization

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GLDJQRVLV PDQDJHPHQW DQG SUHYHQWLRQ 3DHGLDWU 5HVSLU 5HY

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of the epidemiology of the disease pertussis with the
epidemiology of Bordetella pertussis LQIHFWLRQ 3HGLDWULFV
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incidence, clinical manifestations and the role of treatment
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erythromycin estolate for the
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pertussis.
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Paediatr Indones, Vol. 52, No. 1, January 2012 31