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A 48-year-old female with high blood pressure presented with rhinorrhea, productive cough, and back discomfort. Initial treatment for a presumed common cold offered brief symptom relief. However, her condition progressively deteriorated, and further evaluation revealed rib fracture, pneumothorax (collapsed lung), and subcutaneous emphysema. Elevated Bordetella pertussis toxin antibodies confirmed pertussis. Despite recurrent symptoms, she was successfully managed with antibiotics and conservative care. At follow-up, her symptoms had resolved. But, she continued to feel anxious about her condition. This case emphasizes the need for heightened clinical suspicion of pertussis in adults presenting with severe cough and associated complications, particularly amid a global resurgence in pertussis cases.
The patient initially presented with back pain, runny nose, and wet cough. Despite initial treatment for a common cold providing short-term relief, her condition worsened, revealing a rib fracture, pneumothorax, and subcutaneous emphysema upon further assessment.
Pertussis (whooping cough) is a highly contagious acute respiratory illness. It is mainly triggered by Bordetella pertussis and occasionally by Bordetella parapertussis. Pertussis spreads easily through droplets from coughing or sneezing and remains contagious for up to 3 weeks following commencement of symptoms. The disease is particularly dangerous for infants below 2 years of age, leading to substantial morbidity and mortality. Despite extensive vaccination efforts, pertussis cases have witnessed a global resurgence in the past few years.
Pertussis unfolds in 3 distinct stages (each lasting 1-2 weeks) over about 6 weeks: (a) catarrhal, (b) paroxysmal, and (c) convalescent. The catarrhal stage mimics common cold, with symptoms like conjunctival suffusion, tearing, low-grade fever, sneezing, rhinorrhea, and nasal congestion. The paroxysmal phase is marked by severe coughing fits, often ending with a “whoop” sound. It may also involve vomiting after coughing (post-tussive vomiting) and facial redness from the intense coughing. In the final convalescent phase, a persistent long-term cough persists for weeks, despite other symptoms subsiding.
Pertussis can arouse fatal complications, particularly in newborns, young children, and chronically ill people, often due to impaired cerebral oxygenation. To tackle this, effective vaccines were introduced in the 1950s and 1960s, leading to a dramatic decline in pertussis cases and mortality—over 90%—specifically in vulnerable groups like infants and older adults in industrialized countries. Those who are vaccinated generally experience milder symptoms and a markedly reduced risk of complications than those who are unvaccinated. Vaccination also aids in curtailing the secondary attack rate, minimizing the risk of transmission to others.
This is fundamental for safeguarding neonates who are not old enough for full vaccination and teens whose immunity may have diminished over time. In spite of immunization initiatives, pertussis continues to be a concern. The American Lung Association stresses the importance of prompt antibiotic therapy upon diagnosis or suspected exposure, with azithromycin, clarithromycin, and erythromycin being commonly used. Although antibiotics demonstrate limited influence on the time span or magnitude of the ailment in the catarrhal phase and are not so useful during the paroxysmal phase, their main role is to mitigate transmission of the ailment.
The rise in pertussis cases is driven by several factors, including suboptimal immunization coverage and waning immunity, notably among teens and adults who might have missed the booster doses. Inconsistent use of booster shots has triggered greater infection rates in specific areas. Enhanced laboratory analysis and reporting have also caused a spike in diagnosed cases. The COVID-19 pandemic played a significant role, disrupting routine vaccination schedules and limiting healthcare access, which further decreased immunity levels. Additionally, a reduction in diagnoses of other respiratory illnesses, combined with increased social interactions, has contributed to the resurgence of pertussis.
A non-smoking woman (48-year-old) with hypertension, managed with perindopril (angiotensin-converting enzyme inhibitor), showed signs of productive cough, back discomfort, and runny nose. This case study highlights a rare complication of pertussis: cough-triggered rib fracture and recurring lung collapse.
[1] Initial Visit
(a) Presenting Complaints: The patient showed symptoms of runny nose, productive cough, and back pain. She denied fever or breathing distress.
(b) Tests:
Antigen tests for COVID-19, influenza, and respiratory syncytial virus (RSV) were carried out and yielded negative results.
Reverse transcription polymerase chain reaction (RT-PCR) testing was unavailable, and pertussis was not initially suspected.
[2] Second Visit (1 Week Later)
(a) Presenting Complaints: The patient reported worsening back pain, a dry cough, and swelling over her right scapular area extending to the neck. She denied any history of trauma, falls, or other factors contributing to her worsening health status.
(b) Physical Assessment Findings:
In the right upper back and neck, an extensive area of subcutaneous (under the skin) emphysema was detected.
Crepitation (crackling sound) and abnormal breath sounds were noted over the emphysema area.
Her blood pressure and oxygen saturation levels were found to be within normal limits. But, she showed signs of tachycardia.
(c) Imaging:
A chest X-ray and computed tomography (CT) scan revealed a fractured 9th right rib with lateral displacement in the mid-axillary line. Also, there was a 45 mm wide pneumothorax located ventrally at the apex, 15 mm from the pleura, and extensive accumulation of gas or air under the skin.
No pneumothorax was detected on follow-up X-rays, which were performed 3 days after drain removal.
(d) Laboratory Results:
Routine blood tests showed elevated C-reactive protein (71 mg/L) but no other abnormalities.
[3] Third Visit (After First Discharge)
(a) Presenting Complaints and Physical Findings: One month later, the woman visited the clinic. She had a mild cough without any kind of back discomfort. A few days later, she resumed her work duties. However, after 1 day, her back pain and swelling returned. On the right side of her chest, a new pneumothorax and emphysema were found upon assessment.
[4] Additional Hospital-Based Evaluations
(a) Differential Diagnosis Considerations: For exploring the underlying causes of the rib fracture, conditions such as osteoporosis, thyroid/parathyroid disorders, hematological malignancies, and primary/secondary bone tumors were considered.
(b) Bone Density and Fracture Risk:
Osteopenia (bone loss) was detected in both femurs through densitometry.
Fracture Risk Assessment Tool (FRAX) score portrayed a 4.2% risk for major osteoporotic fracture and a 0.8% risk for hip fracture.
(c) Abdominal Ultrasound: No abnormalities were found.
(d) Pertussis Toxin Antibody Levels: Lab testing confirmed recent Bordetella pertussis infection with markedly elevated IgG (350 kU/L, normal <40 kU/L) and IgA (49.8 kU/L, normal <10 kU/L) levels.
Vaccination records for the patient were unavailable. But, pertussis vaccination, as part of tetanus and diphtheria vaccine combination, has been incorporated in the Czech Republic’s schedule since the year 1958. Given the patient’s birth year of 1976, it was likely that she received this vaccine in childhood.
[1] Initial Treatment
The patient was initially treated for symptoms of common cold with:
Mucolytics (erdosteine) for productive cough.
Analgesics for back pain.
She was advised to take rest. Three days later, she felt better and went back to work.
[2] Management of Pneumothorax (First Admission)
(a) Hospitalization: The enrolled patient was transferred to the intensive care unit (ICU) of the regional surgery department.
(b) Interventions:
For 2 days, chest drain insertion was carried out to re-expand the lung.
Antibiotic therapy with amoxicillin/clavulanic acid was given to prevent infections.
Conservative management of the rib fracture without any medical surgery was also executed.
(c) Post-discharge Medications: Codeine was prescribed for dry cough and pain relief, along with activity modification to minimize strain on the rib cage and prevent recurrence.
[3] Management of Recurrent Pneumothorax (Second Admission)
(a) Hospitalization: The patient was readmitted to ICU, then transferred to a university hospital for specialized care.
(b) Interventions:
Reinsertion of the chest drain was done, with emphasis on breathing exercises to promote lung healing.
After 3 days, removal of the chest drain was carried out under X-ray guidance, ensuring no further air leak or repeated lung collapse.
[4] Targeted Therapy for Pertussis
After elevated Bordetella pertussis antibodies were detected, the patient was treated with
Clarithromycin (10 days) to address pertussis infection.
[5] Follow-Up
After being discharged, the patient had a follow-up session with a lung specialist. This included a control X-ray and spirometry. Both the assessments showed normal results. Notably, 2 months after her second hospital stay, she stated full resolution of her cough and back discomfort. However, she experienced substantial anxiety and fear linked to her recent medical conditions.
Pertussis, or whooping cough, remains a critical medical concern, especially when it arouses complications beyond the typical respiratory symptoms. In this situation, a 48-year-old female experienced rib fractures, subcutaneous emphysema, and recurring lung collapse secondary to Bordetella pertussis infection. The hallmark of pertussis is severe and paroxysmal coughing. Such kind of coughing generates pressure alteration within the thoracic cavity.
Over time, repeated bouts of severe coughing can place excessive stress on the ribs, resulting in fractures, especially in those with weakened bones like those with osteoporosis or osteopenia. Rib fractures can then cause sharp bone edges to tear the pleura. This elicits complications such as pneumothorax. Additionally, a persistent cough can elicit sudden escalation in intra-alveolar pressure, which may result in alveolar rupture, subpleural bullae, or pneumothorax. These complications highlight the mechanical burden severe coughing places on the body.
This case is consistent with findings in recent literature. Wang et al. (2022) reported a similar case in an elderly patient suffering from pertussis who experienced rib and vertebral fractures, illustrating the mechanical stress induced by intense coughing in those with osteopenia. Hanak et al. (2019) also documented cough-stimulated rib fractures, with or without pertussis, emphasizing that severe coughing from any cause can precipitate rib fractures. The complications of pertussis extend just beyond the thoracic injuries. A 2021 study by Yeung et al. emphasized that untreated or partially treated pertussis can incite severe outcomes like pneumonia, encephalopathy, and prolonged cough, especially in vulnerable populations, including older adults and individuals with chronic ailments.
Delayed diagnosis amplifies these risks, as the disease can initially mimic common cold symptoms. This case highlights the necessity of taking into account pertussis as a potential diagnosis in adults with long-term cough, even when the symptoms are similar to those of a common cold. Early recognition and treatment can evade severe complications and minimize the burden of disease. As pertussis cases continue to rise globally, particularly in adults, it is crucial for healthcare providers to remain vigilant, ensure timely diagnosis, and tackle complications effectively.
Learning
Pertussis in adults can be easily misdiagnosed, as its early signs mimic those of common cold. It is crucial to consider pertussis as a differential diagnosis, especially when persistent coughing becomes intense. Intense coughing can trigger serious musculoskeletal and pulmonary complications, underscoring the value of timely recognition and intervention. Prompt diagnosis, along with appropriate antibiotic treatment and supportive care, is key to preventing complications and ensuring better outcomes for patients.
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