This article was underwritten by an unrestricted educational grant by Sanofi Pasteur, ACEP’s Official Wellness Supporter.

A previously healthy 24-year-old African American female came to the emergency department complaining of persistent cough and pain in her right lateral chest. The pain started suddenly during a bout of hard coughing that had become chronic. The pain increased with deep inspiration, cough, or certain movements. She had experienced “a little cold” with sneezing, mild occasional cough, and a low-grade fever about 3 weeks prior. But after a week, the cough became worse and was especially bad at night. She couldn’t sleep and felt exhausted.

She had been seen by her private doctor and again at another emergency department and had been diagnosed with “asthmatic bronchitis.” But the inhaler she was prescribed did not help the cough, and she had never suffered from asthma before. She had been prescribed levofloxacin by her doctor along with a steroid dose pack, but he stopped the medication when she called him about heel pain.

Physical exam was unremarkable except for a persistent cough. There were no wheezes, rales, or rhonchi. Her white blood cell count was 16.5k with 60% lymphocytes. Chest x-ray showed moderate hyperinflation but no acute pathology. Rib films failed to demonstrate a fracture. There was motion artifact on the film because she could not keep from coughing. Influenza swab was negative.

The patient admitted that she went to the emergency department that day in part because her two young children were being seen in the pediatric area. Both children had caught her cold, but the baby had developed a fever of 101° F and was now vomiting when she coughed. Both the baby and her brother were coughing so hard “that their faces turned blue,” and their pediatrician had referred them to the emergency department to rule out pneumonia. It had just gotten bad during the previous 24 hours. She said she had not had her children immunized for fear of possible side effects.

Mini swabs were done on the patient’s anterior nasal secretions and sent in for Bordetella pertussis PCR. It is sensitive even after the first day of upper respiratory symptoms and stays positive for up to 14 days after the cough becomes severe. This represents most of the contagious phase of pertussis. The turnaround time on this test for this facility is more than 24 hours, but in many places it is more than 72 hours. She was empirically put on trimethoprim/sulfamethoxazole. She was offered the preferred agent, azithromycin, but she complained of gastric upset with “any of the mycins,” which was presumed to include clarithromycin and erythromycin, the only other agents indicated for pertussis. (Levofloxacin does show some in vitro activity, but there is no clinical evidence of its efficacy against the illness.)