Severe Paroxysmal Coughing and Pleuritic Pain in an Adult

Abstract

A 49-year-old woman presented with severe paroxysmal cough­ ing and disabling pleuritic pain of one week's duration. She had had nasal congestion that she described as different from the usual cold, followed several days after its onset by a nonpro­ ductive cough that became paroxysmal after a week. The patient's job brought her in close daily contact with young children. She had received the usual childhood immunizations and, except for reactive airway disease in childhood, her gener­ al health had been good. Physical examination revealed a haggard, afebrile woman who appeared to be exhausted. The examination was interrupted by remarkable paroxysms of coughing. Each cough was mild, almost like a clearing of the throat, but several came in rapid succession, leaving the patient breathless and forcing a tremen­ dous inspiratory whoop. A sin­ gle paroxysm consisted of three to five rapidly consecutive repe­ titions of this sequence. During the episodes, the patient cried out in pain and held the lower left side of her thorax. The lungs were clear to per­ cussion and auscultation. The remainder of the physical exam­ ination was normal. A chest x-ray revealed normal lung fields and, on close exami­ nation, a fractured left rib (Fig­ ure 1 ). No other laboratory stud­ ies were performed. The clinical diagnosis was pertussis. Clarithromycin was prescribed empirically and, in accordance with public health recommendations, prophylactic antibiotic therapy was initiated in the patient's household contacts. Shortly after the patient start­ ed taking clarithromycin, a na­ sopharyngeal swab was ob­ tained for culture and direct flu­ orescent antibody detection of Bordetella pertussis. Both of these studies were negative, as were cultures for respiratory viruses. After completion of 10 days of treatment, the patient showed no clinical improvement. Parox­ ysms continued at the same fre­ quency and intensity for four weeks, during which she ap­ peared to fracture another rib, this time on the right side of the chest. Coughing subsided slowly during the next three weeks. The entire illness lasted two months. The diagnosis of pertussis was proved serologically. Three blood specimens (a baseline sample drawn two years earlier, one drawn the day the cultures were attempted, and one drawn two weeks later) were submitted to the pediatric infectious disease laboratory at the University of California, Los Angeles Medical Center for measurement of anti­ body to four major antigens of B. pertussis. Dramatic increases in antibody titers were demon­ strated in the two recent speci­ mens (Table 1). Matching sera from the patient's husband con­ tained ample antibody at base­ line and there was no significant increase during his wife's illness.