A 15-month-old full-term boy is brought to the clinic for a well-child examination. He has been eating and sleeping well and is meeting all developmental milestones. His day care center had an outbreak of pertussis 6 weeks ago that required it to close for a few days, but the patient has had no cough, nasal congestion, or rhinorrhea. At age 6 months, he had a generalized seizure that lasted approximately 2 minutes within hours of receiving the diphtheria-tetanus-acellular pertussis vaccine. He was taken to the emergency department for observation and discharged later that day. The patient has had no other seizures or medical concerns and takes no medications. His uncle has a history of childhood-onset epilepsy. Vital signs and physical examination are normal. The child is due for the fourth dose of the diphtheria-tetanus-acellular pertussis vaccine. Which of the following is the best next step in management of this patient?

Question

A 15-month-old full-term boy is brought to the clinic for a well-child examination.  He has been eating and sleeping well and is meeting all developmental milestones.  His day care center had an outbreak of pertussis 6 weeks ago that required it to close for a few days, but the patient has had no cough, nasal congestion, or rhinorrhea.  At age 6 months, he had a generalized seizure that lasted approximately 2 minutes within hours of receiving the diphtheria-tetanus-acellular pertussis vaccine.  He was taken to the emergency department for observation and discharged later that day.  The patient has had no other seizures or medical concerns and takes no medications.  His uncle has a history of childhood-onset epilepsy.  Vital signs and physical examination are normal.  The child is due for the fourth dose of the diphtheria-tetanus-acellular pertussis vaccine.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d238_fe22_bc81_5d999f97a06f_MD0003_00 The diphtheria-tetanus-acellular pertussis (DTaP) vaccine is a combination vaccine containing acellular pertussis antigen with diphtheria and tetanus toxoids. Combination vaccines are safe, effective at preventing infection, and beneficial in reducing the number of needlesticks required (resulting in decreased pain and improved compliance). Children should receive 5 doses of the inactivated DTaP vaccine at ages 2, 4, and 6 months; 15-18 months; and 4-6 years. The risk of an adverse reaction to the DTaP vaccine is low and generally includes minor erythema/swelling at the injection site and/or fever. Seizure, triggered by fever or by the pertussis vaccine component, is rare and is typically short (<5 minutes) and self-limited, as in this child. Patients with a family history of febrile seizures or epilepsy may be at increased risk. However, neither personal nor family history of seizures is a contraindication to immunization. Specifically, uncomplicated seizure following vaccine administration is not a contraindication to future vaccination. The benefit of DTaP vaccination, especially in the setting of a pertussis outbreak, outweighs the unlikely risk of significant side effects. The DTaP vaccine is contraindicated in a few circumstances. When anaphylaxis develops following DTaP administration, the patient should not receive future doses (Choice D). In addition, unstable neurologic disorders (eg, infantile spasms, uncontrolled epilepsy) and encephalopathy (ie, coma, decreased level of consciousness, prolonged seizures) within a week of DTaP vaccine administration are contraindications to the combination vaccine; as a result, diphtheria and tetanus toxoids should be administered without pertussis (Choices A and C). (Choice E) Postexposure antibiotic prophylaxis is indicated for close contacts (eg, household, day care) of anyone with pertussis within the last 21 days. Because this child was exposed to pertussis 6 weeks ago, prophylactic antibiotics are no longer required. Educational objective: Anaphylaxis, unstable neurologic disorders, and encephalopathy (eg, coma, decreased consciousness, prolonged seizures) within a week of administration of the diphtheria-tetanus-acellular pertussis vaccine are contraindications for future administration of pertussis-containing vaccines. However, uncomplicated seizures are not. References: Lack of association between acellular pertussis vaccine and seizures in early childhood. (http://www.ncbi.nlm.nih.gov/pubmed/20643726) Pertussis: a reemerging infection. (http://www.ncbi.nlm.nih.gov/pubmed/24364571) Risk of febrile seizures and epilepsy after vaccination with diphtheria, tetanus, acellular pertussis, inactivated poliovirus, and Haemophilus influenzae type B. (http://www.ncbi.nlm.nih.gov/pubmed/22357833) Comparative effectiveness of acellular versus whole-cell pertussis vaccines in teenagers. (http://www.ncbi.nlm.nih.gov/pubmed/23690518)

A 15-Month-Old Full-Term Boy Is Brought to the Clinic for a Well-Child