A 3-week-old girl is brought to the emergency department due to apnea and cyanosis. Her mother reports multiple episodes over the last 48 hours of gagging and gasping for air. During the last event, the patient started coughing harshly during a feed and then stopped breathing. She became cyanotic for approximately 12 seconds, then quickly returned to normal. The patient has a 1-week history of clear rhinorrhea and increasing cough with episodes of emesis. Temperature is 37.2 C (99 F), blood pressure is 85/52 mm Hg, pulse is 110/min, and respirations are 45/min. She is well developed and active. There is nasal congestion and clear rhinorrhea. Lung sounds are clear except for referred upper airway congestion. Cardiac and abdominal examinations are normal. Which of the following is the most appropriate empiric pharmacotherapy for this patient's condition?

Question

A 3-week-old girl is brought to the emergency department due to apnea and cyanosis.  Her mother reports multiple episodes over the last 48 hours of gagging and gasping for air.  During the last event, the patient started coughing harshly during a feed and then stopped breathing.  She became cyanotic for approximately 12 seconds, then quickly returned to normal.  The patient has a 1-week history of clear rhinorrhea and increasing cough with episodes of emesis.  Temperature is 37.2 C (99 F), blood pressure is 85/52 mm Hg, pulse is 110/min, and respirations are 45/min.  She is well developed and active.  There is nasal congestion and clear rhinorrhea.  Lung sounds are clear except for referred upper airway congestion.  Cardiac and abdominal examinations are normal.  Which of the following is the most appropriate empiric pharmacotherapy for this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d6cc_909b_bc81_c3ceafa84415_MD0003_00 This patient has a severe cough with apnea and posttussive emesis that is concerning for pertussis, a highly contagious infection that is caused by Bordetella pertussis and transmitted through respiratory droplets. Infants (as well as unvaccinated individuals) who have not received the acellular pertussis vaccine are at high risk for infection. The disease typically progresses from a mild cough and rhinorrhea (catarrhal phase) to a harsh, whooping cough with posttusive emesis (paroxysmal phase) before gradual symptom resolution over weeks to months (convalescent phase). In infants, the initial phase may be short/mild or absent, whereas the paroxysmal phase is often particularly severe with gagging, gasping, cyanosis, and life-threatening apnea. Fever is uncommon. Given the risk for serious complications (eg, apnea, seizures), infants with suspected pertussis should receive immediate empiric treatment with a macrolide antibiotic (eg, azithromycin) while awaiting confirmatory testing (ie, pertussis culture, PCR). Antibiotic therapy reduces transmission risk and, if initiated early (within the first week of symptoms), may shorten illness duration. Vaccination is recommended on the routine schedule (age 2, 4, 6, and 12-15 months and 4-6 years). (Choice A) Amoxicillin is used to treat acute otitis media, which typically presents with fever and fussiness in an infant. An ear infection would not cause apnea and cyanosis. (Choice C) Furosemide is a loop diuretic used for heart failure, which can present with poor feeding and cyanosis in infants with congenital heart disease. This patient's normal cardiac examination makes a cardiac etiology less likely. (Choice D) Oseltamivir helps to reduce the symptoms of influenza, which can present with prolonged cough and congestion. However, influenza typically causes high fever, which is not seen in this patient. (Choice E) Ranitidine is an H2-blocker that treats gastroesophageal reflux disease (GERD). Emesis associated with GERD is postprandial rather than posttussive, and GERD does not cause rhinorrhea and congestion. Educational objective: Pertussis is a highly contagious infection characterized by a whooping cough. Infants are at high risk of life-threatening apnea and cyanosis. Empiric antibiotics (eg, azithromycin) reduce transmission and, in some cases, may shorten illness duration. References: Pertussis in young infants throughout the world. (http://www.ncbi.nlm.nih.gov/pubmed/27838663) The prevention of severe pertussis and pertussis deaths in young infants. (http://www.ncbi.nlm.nih.gov/pubmed/30736722)

A 3-Week-Old Girl Is Brought to the Emergency Department Due