Pertussis pneumonia, hypoxemia, hyperleukocytosis, and pulmonary hypertension: improvement in oxygenation after a double volume exchange transfusion

A 3-month-old infant of 33 weeks' gestation was hospitalized with pneumonia caused by Bordetella pertussis. Respiratory insufficiency worsened, and on hospital day 3, there was severe pulmonary dysfunction (arterial oxygen pressure/fraction of inspired oxygen ratio: 120), extreme leukocytosis (white blood cell count 104,000/mm3), and severe pulmonary hypertension as assessed by 2-dimensional echocardiogram. A double volume exchange transfusion was performed to reduce the leukocyte mass. Oxygenation began to improve during the exchange and continued to improve over the ensuing 31 hours (arterial oxygen pressure/fraction of inspired oxygen ratio: 280). The white blood cell count fell dramatically after the exchange, and the rate of rise was slower after exchange therapy compared with preexchange.     

ADad 3: The Epidemiology of Anxiety Disorders Among Adolescents in a Rural Community Population in India

Hyperleukocytosis is defined as peripheral blood leukocyte count exceeding 100,000/mm³. Acute leukemia is the most common etiology in pediatric practice. Hyperleukocytosis is a medical emergency. The increased blood viscosity, secondary to high white cell count and leukocyte aggregates, results in stasis in the smaller blood vessels. This predisposes to neurological, pulmonary or gastrointestinal complications. In addition, patients are at risk for tumor lysis syndrome due to the increased tumor burden. Initial management includes aggressive hydration, prevention of tumor lysis syndrome, and correction of metabolic abnormalities. A red cell transfusion is not indicated in a hemodynamically stable child, as it adversely affects the blood viscosity. Leukapheresis is the treatment of choice for a very high count, or in patients with symptomatic hyperleukocytosis. The technical expertise required, a relative difficult venous access in younger children, risk of anticoagulation and possible non-availability of the procedure in emergency hours are limitations of leukapheresis. However, it is a rewarding procedure and performed with relative ease in centers that perform the procedure frequently. An exchange transfusion is often a practical option when hyperleukocytosis is complicated with severe anemia. The partial exchange aids in correcting both, without the risk of volume overload or hyperviscosity, which are the limitations of hydration and blood transfusion, respectively. Etiology and management of hyperleukocytosis in relevance to the pediatric emergency room is outlined.     

Leukoreduction in patients with severe pertussis with hyperleukocytosis

When pertussis is associated with hyperleukocytosis, mortality approaches to 80%. Immature leukocytes have been identified in pulmonary arterioles, small arteries and venules. Techniques aimed at reducing leukocyte mass might improve the prognosis of these patients. We report our experience with 3 patients in whom a leukoreduction was performed in the context of severe pertussis and hyperleukocytosis.     

Malignant pertussis in the young infant]

Pertussis remains in France the first cause of bacterial, infectious death in infant aged 10 days to 2 months. It is especially in this age group that malignant pertussis occurs. CASE REPORT: A 40-day-old infant was admitted in the intensive care unit with symptoms of bronchiolitis along with a 200 bpm permanent tachycardia. He presented a marked leukocytosis with lymphocytosis. On the second day, convulsions and coma occurred, followed rapidly by respiratory failure, with a subsequent deterioration due to the development of severe pulmonary hypertension. Circulatory failure caused the infant's death on the beginning of the 5th day. Pertussis was confirmed by PCR on nasopharyngeal swab. Intra-familial contamination was most likely. COMMENTS: Malignant pertussis is characterized by the very young age of patients, permanent tachycardia sine materia, dyspnea with early respiratory failure, frequent neurological symptoms, severe hyperleukocytosis and hyperlymphocytosis, and deep hyponatremia with oliguria and edema. Mortality remains superior to 75% despite the various treatments and life support measures that have been attempted. Adult pertussis, which represents one third of the cases of prolonged cough in this age group, is the main source of contamination of non-immunized young infants. This mode of transmission stresses the importance of the generalization of pertussis vaccine booster in early adolescence, which is recommended in France since 1998. Its extension towards the adult age is under study.     

Acute lymphoblastic leukemia with hyperleukocytosis, sinus pauses, and hypoxemic respiratory failure in an infant

A 5-month-old female infant presented with new-onset acute lymphoblastic leukemia and hyperleukocytosis with white blood cell count of 352 × 10(9) cells/L. She developed sinus pauses and hypoxemic respiratory failure. A manual single volume exchange blood transfusion was done with complete resolution of sinus pauses and hypoxemia.     

Severe pertussis, progression and exchange transfusion as an alternative treatment: Case reports

Pertussis is a contagious disease that may develop a serious clinical picture by hypoxemia and pulmonary hypertension refractory to treatment. The syndrome of hyperviscosity and arteriolar thrombosis is responsible for the cardiocirculatory collapse. Our objective is to describe the evolution of a series of patients with severe pertussis, some of whom received exchange transfusion (ET) as an alternative treatment. We analyzed 41 patients' clinical charts with diagnosis of pertussis treated in the Pediatric Intensive Care Units during the 2003-2011 period. The mean age was 2.38 months. In the 90.2% of cases, the cause of admission to PICU was respiratory failure; 75% required mechanical respiratory support and 39% developed pulmonary hypertension. The overall mortality was 41.4%. Nine patients were treated by ET, 5 died. Conclusion. Severe pertussis is associated with high mortality. ET reduced the mass of circulating leukocytes in 53.5%; ET could be an alternative to conventional treatment, although controlled studies are required to assert it.     

百日咳疫苗接种对婴幼儿百日咳临床表现的影响

目的 探讨百日咳疫苗接种对婴幼儿百日咳临床表现的影响.方法 回顾性分析不同百日咳疫苗接种状态的百日咳婴幼儿临床表现及外周血细胞水平的差异.结果 共入组1083例<3岁百日咳患儿,其中未接种组551例,接种组532例;发病年龄<3月龄392例,含未接种372例,接种20例;≥3月龄691例,含未接种179例,接种512例...     

Increase in deaths from pertussis among young infants in the United States in the 1990s

BACKGROUND: Severe pertussis primarily occurs among infants (<12 months of age). Despite high levels of immunization, reported pertussis cases increased in the United States in the 1990s among all age groups, including infants. METHODS: To characterize fatal pertussis cases, we analyzed pertussis deaths reported to CDC in the 1990s and compared these with data on pertussis deaths reported in the 1980s. Data from national surveillance systems and from available medical records were used, including data from analyses of deaths reported in 1992 through 1995. RESULTS: In 1980 through 1989, 77 pertussis deaths were reported; 61 deaths were among infants (1.67 deaths per million), including 49 among infants <4 months of age. In the 1990s 103 pertussis deaths were reported; 93 deaths were among infants (2.40 deaths per million), including 84 among infants <4 months of age. Of 89 infants with ethnicity data, 31 (36%) were Hispanic; the mortality rate among Hispanic infants (4.77 per million) was higher than among non-Hispanic infants (1.80 per million). Of 76 infants with reported gestational age, 40 (53%) were born at <37 weeks, including 22 (29%) who were born at <35 weeks. Severe pulmonary hypertension was a common lethal complication among infants. CONCLUSIONS: Pertussis deaths increased among infants too young to be protected by immunization. A disproportionate share of deaths were complicated by pulmonary hypertension and occurred among Hispanic infants and infants born at <37 weeks gestation. New approaches to prevent infection among infants <4 months of age and improved therapies for pertussis complications are needed.     

Pertussis symptoms in adolescents and children versus infants: the influence of vaccination and age

This study compared the influence of age and immunization status on symptoms in pediatric patients with pertussis. The files of 60 children, aged 7 to 18 years and 20 infants aged up to 6 months, admitted to our pediatric hospital with a diagnosis of pertussis were reviewed. There were no between-group differences in day and night cough or vomiting. The older group had a longer mean interval to diagnosis than the infants, and the infant group had more symptoms of whooping cough, facial redness during cough, cyanosis, a higher white blood count, a higher percentage of lymphocytes, and more abnormal chest X-rays. Statistically significant differences were found between vaccinated and unvaccinated older children for whooping cough and white blood cell count. Daytime and nighttime coughs are common symptoms of pertussis in all pediatric age groups, regardless of vaccination status. High white blood count is related to immunization status, and percentage of lymphocytes is related to age. In infants, symptoms are more grave but are typical, leading to early diagnosis.     

妊娠期高血压疾病对胎龄28~34周早产儿外周静脉血细胞计数的影响

目的 探讨母亲妊娠期高血压疾病（hypertensive disorders of pregnancy,HDP）对胎龄28~34周早产儿外周静脉血细胞计数的影响。 方法 选取2020年1~12月昆明医科大学第一附属医院儿科收治的母亲合并HDP的胎龄28~34周早产儿227例为研究组,另选取同期收治的母亲无HDP的胎龄28~34周早产儿227例为对照组。研究组根据母亲妊娠期血压分为妊娠期高血压亚组（75例）、轻度子痫前期亚组（81例）、重度子痫前期亚组（71例）;根据早产儿出生体重分为小于胎龄儿（small for gestational age,SGA）亚组（113例）及适于胎龄儿（appropriate for gestational age,AGA）亚组（114例）。比较研究组和对照组、研究组各亚组间早产儿生后第1天外周血细胞计数的差异。 结果 研究组患儿生后第1天外周静脉血白细胞（white blood cell,WBC）计数、中性粒细胞绝对计数（absolute neutrophil count,ANC）及血小板（platelet,PLT）计数均低于对照组（P<0.05）,白细胞减少症、中性粒细胞减少症发生率高于对照组（P<0.05）。亚组分析中,轻度子痫前期亚组、重度子痫前期亚组WBC计数、ANC、PLT计数均低于妊娠期高血压亚组（P<0.05）;SGA亚组WBC计数、ANC、PLT计数低于AGA亚组（P<0.05）。 结论 HDP可对早产儿外周静脉血细胞计数产生影响,这一影响在母亲子痫前期及SGA早产儿中更为显著。     

Exchange transfusion in newborns via a peripheral artery and vein

Exchange transfusion using a peripheral artery and vein was carried out 18 times in 17 newborn infants. The arteries used to withdraw blood were the radial [13], the ulnar [3] and the posterior tibial [2]. Infusion of blood was carried out simultaneously through a peripheral vein. There was no mortality or morbidity directly associated with the procedure. We recommend this technique for exchange transfusion in general, and especially in the very ill newborn.     

Transfusion in premature infants impairs production and/or release of red blood cells,white blood cells and platelets

OBJECTIVE: To examine whether red blood cell transfusion in infants with anaemia of prematurity alters peripheral counts of red blood cell precursors, total white blood cells and white cell differential and platelets. METHODOLOGY: In 18 consecutive stable premature infants with anaemia of prematurity, peripheral cell counts were prospectively recorded immediately before transfusion of 20 mL/kg packed red blood cells (given over 6 h), and at 48 h after completion of the transfusion. RESULTS: The median (interquartile range) haematocrit increased from 22.0% (21.3-24.0%) pre-transfusion to 37.0% (36.0-38.0%) post-transfusion (P < 0.001). Red-cell precursors decreased: median (interquartile range) reticulocytes from 3.7% (3.0-7.7%) to 3.7% (2.6-4.1%) (P = 0.03); and median (interquartile range) nucleated red blood cells from 0 G/L (0-0.2 G/L) to 0 G/L (0-0 G/L) (P = 0.03). The mean (SD) platelet count decreased from 420 G/L (154 G/L) to 313 G/L (101 G/L) (P = 0.001). The total white blood cell count and neutrophils did not change significantly; however, median (interquartile range) immature neutrophils decreased from 0.12 G/L (0.06-0.74 G/L) to 0.08 G/L (0.01-0.24 G/L) (P = 0.03). Lymphocytes, eosinophils, basophils and plasma cells remained unchanged. Monocytes increased (P = 0.01). CONCLUSIONS: Forty-eight hours after red blood cell transfusion to premature infants, there is an absolute decrease in red blood cell precursors, immature white blood cells and platelets, probably due to erythropoietin-suppression.     

Neonatal jaundice in Asian, white, and mixed-race infants

BACKGROUND: East Asians have inherently higher bilirubin levels at birth than whites. The potential for unnecessary treatment makes jaundice a problem of public health and clinical significance. OBJECTIVES: To report the occurrence of jaundice diagnoses in East Asian and mixed East Asian/white infants in Washington State in recent years, and to compare the risk of diagnosis with neonatal jaundice among these infants, relative to white infants. DESIGN: Population-based cohort study in Washington state. Participants were infants of full East Asian parentage (n = 3000), maternal Asian parentage (n = 2997), paternal Asian parentage (n = 2048), and white parentage (n = 3000). Diagnoses of jaundice and "severe jaundice" were identified using International Classification of Diseases, Ninth Revision (ICD-9) diagnosis and procedure codes from hospital discharge records. RESULTS: Infants of full East Asian parentage were more likely to be diagnosed with jaundice than were white infants (relative risk [RR], 1.37; 95% confidence interval [CI], 1.16-1.62). For infants with Asian mothers and white fathers, the RR was 1.09 (95% CI, 0.91-1.30). Infants with Asian fathers and white mothers had an RR of 1.26 (95% CI, 1.05-1.52). The risk of severe jaundice requiring phototherapy, blood transfusion, or rehospitalization, however, was significantly elevated only for infants of full East Asian parentage (RR, 1.7; 95% CI, 1.12-2.58). CONCLUSIONS: Diagnoses of neonatal jaundice occurred more often among East Asian and mixed Asian/white infants than among white infants. However, the risk of jaundice requiring extended hospital stay, rehospitalization, phototherapy, or blood transfusion was elevated only for infants of full East Asian parentage.     

Glucagon,Insulin, and Growth Hormone Response to Exchange Transfusion in Premature and Term Infants

Exchange transfusions were performed on premature or term infants using blood preserved with acid citrate and glucose. The plasma concentrations of glucose, free fatty acids, insulin, glucagon, and growth hormone were measured in the donor blood and in blood from the infant at different times during the transfusion. The total amounts of metabolite and hormone infused and removed from the infant were calculated. The exchange transfusion caused a larger rise in plasma glucose of premature infants than of term infants, due in part to a higher plasma glucose in the donor blood used for premature infants. Despite the higher plasma glucose levels, the premature infants secreted less insulin in response to the glucose challenge, as judged by the rise in plasma insulin and the insulin balance. The transfusions were associated with increased growth hormone secretion in both groups. Premature infants secreted more growth hormone per kg bodyweight than term infants. Plasma glucagon levels in term and premature infants before transfusion were higher than those found in normal infants under comparable conditions. The transfusion caused a similar fall in plasma concentration and a similar negative balance of free fatty acids and glucagon in each group.     

Impact of delivery mode and gestational age on haematological parameters in Taiwanese preterm infants

Aim:   Reference ranges of haematological parameters in preterm infants are limited. The aim of this study is to determine the reference values of haematological parameters in preterm infants in Taiwan, and to assess the impact of gestational age and mode of delivery on these parameters.
Method:   Medical records were retrospectively reviewed in preterm infants admitted to National Taiwan University Hospital from January 2001 to December 2004. The inclusion criteria included infants with <37 weeks of gestation who had blood sampling within 24 h of birth. The exclusion criteria included those with maternal history of antepartum haemorrhage, chorioamnionitis, fever, sepsis, preeclampsia and hypertension; and perinatal history of twin-to-twin transfusion syndrome, feto-maternal transfusion, injury and infection.
Results:   Of 568 preterm infants with blood cell counts, 337 were available for analysis. There were trends of increase in red blood cell counts, haemoglobin levels and haematocrit values as gestation increased up to 34 weeks. In contrast, a trend of decrease was noted in mean corpuscular volume values. There was an initial trend of decrease in white blood cell counts and then increased after 31 weeks gestation. The platelet counts were essentially unchanged. Infants born by vaginal delivery generally had higher haematological parameters than those born by Caesarean section at different gestational ages except for mean corpuscular volume values.
Conclusions:   We established the reference ranges of haematological parameters in Taiwanese preterm infants. Health-care professionals must be cautious in clinical application of the haematological values because of varying antenatal and perinatal risk factors.     

新生儿MN溶血病一例并21例文献复习

目的 探讨新生儿MN溶血病的临床特点及诊治经验,更好地预防治疗本病.方法 报道新生儿MN溶血病1例,并对国内近20年来已报告的21例进行文献复习.结果 新生儿MN溶血病的报道有增多趋势.有4/22例发生于第1胎,男:女=10:8;患儿血型19/21例为MN、2/21例为M,其母血型10/21例为N、11/21例为NN;直接抗人球蛋白试验7/18例为阳性、4/18例为弱阳性、7/18例为阴性,抗体释放试验13/16例为阳性、3/16例为阴性,游离抗体试验17/17例为阳性;母抗体类型:21/21例IgG抗-M均(+),10/21例IgM抗M亦(+);患儿抗体类型:22/22例均为IgG抗M(+);患儿均有不同程度的贫血、黄疸;11/15例在出生24 h内出现黄疸;4/13例直接胆红素也明显增高;出现黄疸后,多数给予了光疗;4/15例给予了大剂量静脉注射免疫球蛋白;8/22例实施了换血治疗;死亡3/22例、治愈19/22例.结论 抗-M抗体引起的新生儿溶血病其病情轻重相差较大,重者甚至死胎或者需要换血.对于反复死胎、流产、胎儿水肿、严重贫血或多年不育的患者,在排除了其他原因及新生儿ABO、Rh溶血病后,应查MN血型及其抗体进一步明确本病.有效的光疗、效果显著的大剂量静脉注射免疫球蛋白、金属卟啉类药物等治疗,已经明显减少了需要换血的患儿数量.换血多采用全自动周围血管双管同步换血法.     

Leukopheresis therapy for severe infantile pertussis with myocardial and pulmonary failure.

OBJECTIVE: To describe an infant with severe pertussis successfully treated with leukopheresis. DESIGN: Case report. SETTING: Pediatric intensive care unit of a children's hospital. PATIENT: Five-wk-old female with pertussis complicated by cardiorespiratory failure. INTERVENTIONS: Single leukopheresis treatment. MEASUREMENTS AND MAIN RESULTS: Normalization of the white blood cell count and marked cardiorespiratory improvement after treatment; patient survived. CONCLUSION: Given the temporal association between treatment and improvement, we hypothesize that the markedly elevated white blood cell count has a major role in the cardiopulmonary compromise.     

Echocardiographic outcome of infants treated as newborns with inhaled nitric oxide for severe hypoxemic respiratory failure

OBJECTIVE: To determine the cardiovascular outcome of a group of term newborns treated with inhaled nitric oxide (iNO) for severe hypoxemic respiratory failure with associated persistent pulmonary hypertension. STUDY DESIGN: We performed echocardiographic evaluations in 40 survivors treated for severe neonatal hypoxemic respiratory failure. Each of the 40 had at least 2 follow-up echocardiograms at 3 or 6 and 24 months. These studies were compared with echocardiograms done in infants in a normal, age-matched control group. RESULTS: Three of 31 infants met echocardiographic criteria for pulmonary hypertension at the 3-month examination. Two of the 3 had associated structural heart disease (1 with an atrial septal defect and 1 with a ventricular septal defect). At 24 months only 1 patient had pulmonary hypertension. This infant had an atrial septal defect that was surgically closed shortly after the 24-month echocardiogram because of the pulmonary hypertension. Group comparisons of 3- and 24-month echocardiographic variables showed no differences between the study and control groups. In the 31 infants in whom serial studies were completed, expected age-related changes were demonstrated between the 3- and 24-month examinations. CONCLUSIONS: The incidence of residual pulmonary hypertension in infants treated as newborns for severe hypoxemic respiratory failure is low. The group at highest risk is those with structural heart disease.     

Excessively high bilirubin and exchange transfusion in very low birth weight infants

Aim: To evaluate the performance of exchange transfusion in very low birth weight (VLBW) infants with excessively high serum bilirubin levels. Methods: A population‐based observational study using data collected by the Israel National VLBW Infant Database. The study sample comprised 13 499 infants. Two definitions of excessively high‐peak bilirubin levels that might be considered as threshold levels for performance of exchange transfusion were used. First, a bilirubin level of ≥15 mg/dL for all infants (PSB‐15), and second, incremental bilirubin levels ranging from 12 to 17 mg/dL according to gestational age (PSB‐GA). Results: Four hundreds sixty‐eight (3.5%) and 1035 infants (7.7%) infants in the PSB‐15 and in the PSB‐GA groups respectively had peak serum bilirubin levels above thresholds for exchange transfusion. Exchange transfusions were performed in 66 (14.1%) of these infants in the PSB‐15 group and 91 (8.8%) in the PSB‐GA group. Using logistic regression analysis, peak serum bilirubin was found as an independent factor for performing exchange transfusion. Conclusion: Exchange transfusion was performed in only 9–14% of VLBW infants with excessively high bilirubin levels. We speculate that this may be a result of an absence of definitive guidelines or the possible belief that the risks of exchange transfusion outweigh the potential risk of bilirubin‐induced neurological injuries.     

Treatment of severe pertussis by administration of specific gamma globulin with high titers anti-toxin antibody

Our patient presented with severe respiratory distress and marked pleocytosis. She was mechanically ventilated and received gamma globulin with high titers of anti-pertussis toxin and anti-filamentous hemagglutinin. Her clinical signs improved and a notable decrease in white blood cell count was observed. Ten months after treatment, the patient showed normal physical and mental development and anti-pertussis toxin and anti-filamentous hemagglutinin titers were significantly increased. Recently, the effectiveness of gamma globulin therapy has been emphasized again. Our experience supports the use of iv gamma globulin infusion. Also, gamma globulin did not influence the patient's own immunologic response to pertussis. Gamma globulin therapy with high anti-pertussis toxin titers could be considered for treatment of severe pertussis.