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Dear Doctor,

If your patient gives you this, it is as a result of my advice to do so, so please indulge me and your patient by giving it some consideration. www.whoopingcough.net exists to help patients with it to get diagnosed by their own doctor.

Whooping cough AS IT REALLY IS in the developed world today. 

It is not like the traditional descriptions that you read about in most textbooks, or how you have learnt it. Text book descriptions are of a perceived stereotype illness and have been copied from each other down the years. They do not describe pertussis infection as it usually presents nowadays.

This page is to help inform doctors about whooping cough so they can diagnose and support their patients. Some of them may have been referred to this site by patients who have visited here, found it informative and wish to share the information with their physician.

I will tell you who I am, as you will not necessarily want to scrutinize the whole site. My name is Doug Jenkinson. I am a family doctor in Nottingham, England. I have made a special study of whooping cough in the community in which I work (11,000 patients) over the last 30 years. I have meticulously studied every case of whooping cough that has occurred in this time (over 700), and built up a good working knowledge of the disease as it affects individuals. I have published extensively on the subject. (most relevantly 'Natural course of 500 consecutive cases of whooping cough: a general practice population study. Jenkinson D. Br Med J 1995;310,299-302.')

The issue with whooping cough is the extreme difficulty of making a diagnosis. There is little doubt that most cases go undiagnosed by doctors. Some of these patients find the diagnosis for themselves with the aid of a site like this, but then usually have the diagnosis rejected by their doctor.

The reasons for the difficulty are simple. There are four difficulties and misconceptions

1.    Most doctors are not familiar with the unique character of the sound of a whooping cough paroxysm because they have never heard one or had the opportunity to hear one. 

2.    Doctors believe that whooping cough is a severe and serious illness causing frequent coughing and that they could not possibly miss such a diagnosis if their patient had it. In fact, most patients feel and look perfectly well with whooping cough and usually go for many hours at a time between paroxysms. So you are most unlikely to hear a patient with whooping cough who coughs at all. And we are all so used to patients exaggerating the severity of their symptoms, that a patient with whooping cough describing their cough accurately sounds just like a patient with an ordinary cough using a bit of poetic license.

3.    Doctors think it is rare. Wrong. It is far more common than we think. Because it is unrecognized, few cases are officially notified. This reinforces the idea of rarity. Research from several different sources confirms that may be roughly 50 times more common than is recognized.

4.    Doctors think it has been immunized out of existence. Wrong. The effect of immunization only lasts a few years. Adolescents and adults become vulnerable once again.  Adults can now get it and pass it to their children. (A recent concern)

How do you diagnose it? (read below about saliva testing. NEW!)

First you need a high index of suspicion.

Second, you need to know that when it occurs it still tends to be in small outbreaks in a school or church community. You should find several cases. Such clusters are strongly in favor of pertussis as the cause.

Thirdly, outbreaks tend to occur every 4 to 6 years. The intervals are variable and probably reflect the underlying immunization rate.

Fourth is the history, and is without doubt the most important factor in diagnosis. Most patients, or parents of children with whooping cough do not give a history spontaneously that allows the diagnosis to be made. That is why a high index of suspicion is the first requirement. However, when it occurs in clusters, as it usually does, some of them will give you a classical history if you can recognize it. So when you have found your first case you can assume there are others about and start asking the right questions. You do not need me to tell you how to elicit a correct history for this sort of illness, but the symptoms you are looking for that make it whooping cough are as follows.

 It can start in one of two ways generally. The most common is a very sore throat, slight malaise and sometimes a mild feverishness, that after 3 or 4 days turns into an unremarkable dry cough and after 10 days from the very start of symptoms starts to become paroxysmal. In the third week and for the next 4 to 24 (roughly) weeks the cough generally is almost exclusively paroxysmal. Thus after 2 weeks from the start of the illness the diagnosis is made from the existence of paroxysms of coughing that continue for at least 2 weeks. A typical paroxysm comes unexpectedly (but may be precipitated by a change in temperature, or peculiar things such as a particular food). It is a succession of dryish coughs that follow each other without any inspiration so that the lungs become empty of air and the patient obviously develops severe facial congestion. There sometimes follows a brief period of a feeling of suffocation, and cyanosis may occur. Then sometimes (about 50% of patients) will occasionally, when inspiration suddenly comes back with a rush, make an inspiratory stridulous 'whoop'. The paroxysm may be repeated several times leaving the patient exhausted. There then follows a long period before the next paroxysm. Children tend to have about 10 paroxysmal a day at their worst, but adults will commonly only have 2 or 3 a day. It usually causes onlookers as much distress as the patient! (another useful history point). Paroxysms are commonly associated with coughing up sticky mucus and reflex copious salivation. Most patients will retch after a paroxysm as a matter of course. About 50% vomit at some time. 
It can also start with coryzal upper respiratory symptoms and a more moist cough before it turns into the typical paroxysms. This is in fact the usual textbook description, which in my experience only occurs in about a third. (My theory is that pertussis pure and simple, causes only the sore throat and dry cough start, but that is commonly invades a respiratory tract previously made vulnerable by inflammation by a virus, asthma or whatever, and that the early symptoms are frequently a combination of pertussis and the underlying inflammatory cause). That is why the physical findings, that are described next, can also suggest an alternative (and more sometimes desirable) diagnosis.

There are very often no abnormal physical signs. Sometimes there are added sounds in the chest. Sometimes a few wheezes (particularly if the patient has asthma, but usually asthmatics have a reduction in their level of wheeze when they get whooping cough). Sometimes there are a few crackles. None of these adventitious sounds or their absence are a help in diagnosing whooping cough but they obviously raise differential diagnoses that will inevitably be difficult to verify if it is actually whooping cough (back to getting a good history).  Sometimes there is secondary bacterial infection which might give some signs. There may concomitant respiratory infections to confuse the picture in whooping cough ( the history will stand a chance of sorting it).

If you diagnose all the cases of whooping cough that occur the average duration from start to finish is about six weeks. If you only diagnose the more severe cases the duration is more likely to be 3 months. With all grades in between of course.

Proof of whooping cough has been difficult but is getting easier. A positive per nasal swab is wonderful when it happens but by the time most cases are recognized the bugs have gone. PCR testing is a better test on nasopharyngeal aspirate if your lab can do it. Serology is done differently in different parts of the world, and some tests give too many false positives and false negatives. In some places (United Kingdom for example, NHS labs can measure anti pertussis toxin IgG on a single sample of blood or oral fluid at least 2 weeks into the illness and give valuable diagnostic result. Just send a blood sample requesting 'pertussis antibodies' or oral fluid as used in measles or rubella testing). It is all usually down to the history and a clinical diagnosis. Oral fluid testing is likely to be the future method.

What about treatment? There isn't any really. Sick infants need hospitalization for assessment quite often, and if severe may benefit from antibiotics, steroids and oxygen. Others generally just need erythromycin or azithromycin to kill Bordetella organisms to stop infectivity.  If the same is given during incubation the disease may be aborted. Management involves checking for complications such as pneumonia and supporting the parents of children in their coping with what is an exhausting experience for all the family. Pernasal swabs or blood specimens may be tested according to the advice of your laboratory. Negative tests do not exclude whooping cough as a diagnosis. The key is the sound of whooping cough, which you can hear from recordings on this site.

Thank you for reading this.      www.whoopingcough.net

If a doctor in the United Kingdom wishes to phone me I can be reached on 0115 9373527 in office hours.

The following is an email from a patient with typical difficulty getting a doctor to diagnose whooping cough. It is worth reading.

Hello,

We live in Massachusetts, USA and after three weeks, including one hospital trip, four doctors visits, and many, many nights of constantly interrupted sleep, we finally got a diagnosis of whooping cough for my 12 year old twin boys.

What made this particularly frustrating was the fact that I had brought up the idea of the disease to the doctors over a week ago, and my kids were not immunized against it, and the dr's knew that - but they just didn't believe me when I described the severity of the symptoms. The boys were not very "sick" when we visited the doctors. In the last three weeks the boys were tested for strep (negative) and diagnosed with allergies (dog and pollen), sinus infections and "cough" (what the heck does that mean!). They were given an Albuterol inhaler, a Flovent inhaler, Singulair pills, Robitussin cough syrup, codeine cough syrup, over-the-counter Sudafed (decongestant), Rhinocort nasal spray and a pill called Hydrocodone to knock them out at night to help them sleep. We also tried homeopathic Phosphorus 30C pills. And we went out and got an air-purifier! I am sure you are not surprised that nothing worked - not even the Hydrocodone.

Then the school nurse called (for the umpteenth time) and really encouraged me to look into whooping cough again. I found your site and got the courage to go back to the dr's. I told the nurse and dr that we were NOT GOING TO LEAVE the office until they heard one of my kids have a "whooping session". Well, after about 35 minutes one of them launched into a particularly dramatic spasm with the coughing, whooping, red face, loss of breath, sticky foamy saliva, vomit and all. They almost couldn't believe it, because otherwise, my child just looked and sounded a bit under the weather. I said "See, I told you! This is what has been keeping us up at night for weeks! This is why I have been afraid to leave their side because I thought he would choke and die!"

Anyway, that's our story. Thanks for the informative site. It was clear, interesting and put my mind at ease. I am sure we have many more weeks of whooping - but the boys were put on Zithromax and the school is going to let them go on their BIG 6th grade overnight field trip next week. And our doctor assured me that they won't stop breathing!  

PLEASE MAKE SURE PEOPLE KNOW THAT THE KIDS CAN SEEM "WELL" IN-BETWEEN BOUTS!
I know you cover this on the site, but it cannot be reiterated too strongly. This has been a truly amazing experience...with the irony that it took a school nurse and a Mom to get the doctors to listen.

I am going to take a nap!

Sincerely,

DW