Adult Pertussis Is Hazardous for the Newborn

We report 4 cases involving the likely transmission of pertussis from parents to newborns in a hospital setting. The adoption of proper infection control measures and targeted screening of parents may reduce the potential for such transmission.

The Decline of Pertussis-Specific Antibodies After Tetanus, Diphtheria, and Acellular Pertussis Immunization in Late Pregnancy

We prospectively measured pertussis-specific antibodies 9-15 months after delivery in women immunized with tetanus, diphtheria, and acellular pertussis (Tdap) after the 20th week of their recent pregnancy. The Tdap-immunized women (n = 38) exhibited a decline in geometric mean concentrations between their peripartum and follow-up levels for immunoglobulin G to pertussis toxin (21.48 [95% confidence interval, 12.51-36.89] vs 11.72 [7.09-19.37] IU/mL];); filamentous hemagglutinin (185.95 [157.93-218.94] vs 140.33 IU/mL [113.46-173.57] IU/mL); and pertactin (171.52 [120.73-243.67] vs 83.74 [60.58-115.75] IU/mL) (all P < .001). For women immunized with Tdap during late pregnancy, pertussis-specific immunoglobulin G levels decreased significantly 9-15 months after delivery.

The significance of allergic contact urticaria to milk in children with cow's milk allergy

BACKGROUND

Cow's milk allergy (CMA) is the most common food allergy in infancy. Food allergy is generally triggered through ingestion, but can also be triggered through skin contact. We investigated the incidence and the clinical significance of cow's milk protein (CMP)-induced contact urticaria in individuals with CMA with and without atopic dermatitis (AD).

METHODS

A total of 157 children of whom 133 were diagnosed with CMA were participated. The study was based on observational data gathered in the course of patient care, including a skin prick test and a 'finger test', in which cow's milk is applied on the cheek by a physician's finger to detect contact urticaria.

RESULTS

Eighty nine of 133 patients (66.9%) had IgE-mediated CMA. Forty of these 89 (44.9%) tested positive in the finger test. Family atopy was higher in those with positive contact urticaria [21/40 (52.5%) vs. 14/49 (28.5%), p = 0.029]. Patients with positive vs. negative CMP contact urticaria had higher incidence of multiple food allergies [20 of 40 (50%) vs. 7/49 (14.3%), p < 0.004]. IgE-mediated CMA patients with AD had statistically higher CMP allergic contact urticaria compared to patients without AD [71% (15/21) vs. 37% (25/68), p = 0.0064]. Children with non-IgE milk allergy and healthy control group did not have contact urticaria to CMP.

CONCLUSION

CMP contact urticaria exists only in patients with IgE-mediated CMA. A 'finger test' to CMP should be part of the evaluation of CMA patients, and positivity suggests the potential for multiple food allergies, especially to sesame and egg.

Immunization of pregnant women against pertussis: the effect of timing on antibody avidity

BACKGROUND

The Centers for Disease Control and Prevention recommend tetanus-diphteria-acellular pertussis (Tdap) immunization during pregnancy, preferably at 27-36 weeks gestation.

AIMS

First, to assess the relative avidity index (RAI) of umbilical cord immunoglobulin G (IgG) to pertussis toxin (PT) for newborns of women immunized with Tdap during late pregnancy as compared to unimmunized women. Second, to assess whether there is a preferential period of gestational Tdap immunization that provides the highest RAI of umbilical cord IgG to PT.

METHODS

RAI of IgG to PT was assessed via an adapted ELISA using NH4SCN as a dissociating agent.

RESULTS

We found that newborns of women immunized with Tdap during late pregnancy (n=52) had higher mean RAI of umbilical cord IgG to PT than those of unimmunized women (n=8), 73.77%±12.08 (95% CI, 70.41-77.13) vs. 50.23%±21.32 (95% CI, 32.41-68.06), p<0.001. Further, the RAI of umbilical cord IgG to PT was significantly higher in newborns of women immunized at 27-30(+6) weeks gestation (n=20) when compared with newborns of women immunized at 31-36 weeks (n=22) and >36 weeks (n=7), 79.53%±5.61 (95% CI, 76.91-82.16) vs. 71.56%±12.58 (95% CI, 65.98-77.14) vs. 63.93%±17.98 (95% CI, 47.31-80.56), p<0.03.

CONCLUSION

Gestational Tdap immunization between 27 and 30(+6) weeks resulted in the highest avidity of IgG to PT conveyed at delivery as compared with immunization beyond 31 weeks gestation. Future studies should be conducted to confirm our findings to optimize pertussis-controlling strategies.

The effect of timing of maternal tetanus, diphtheria, and acellular pertussis (Tdap) immunization during pregnancy on newborn pertussis antibody levels - a prospective study

BACKGROUND

The Centers for Disease Control and Prevention recommend Tdap immunization during pregnancy, preferably at 27-36 weeks.

AIM

To ascertain whether there is a preferential period of maternal Tdap immunization during pregnancy that provides the highest concentration of pertussis-specific antibodies to the newborn.

METHODS

This prospective study measured pertussis-specific antibodies in paired maternal-cord sera of women immunized with Tdap after the 20th week of their pregnancy (n=61).

RESULTS

The geometric mean concentrations (GMCs) of Immunoglobulin G (IgG) to pertussis toxin (PT) were higher in the newborns' cord sera when women were immunized at 27-30(+6) weeks (n=21) compared with 31-36 weeks (n=30) and >36 weeks (n=7), 46.04 international units/milliliter (IU/mL) (95% CI, 24.29-87.30) vs. 8.69IU/mL (95% CI, 3.66-20.63) and 21.12IU/mL (95% CI, 7.93-56.22), p<0.02, respectively. The umbilical cord GMCs of IgG to filamentous hemagglutinin (FHA) were higher in the newborns' cord sera when women were immunized at 27-30(+6) weeks compared with 31-36 weeks and >36 weeks, 225.86IU/mL (95% CI, 182.34-279.76) vs. 178.31IU/mL (95% CI, 134.59-237.03) and 138.03IU/mL (95% CI, 97.61-195.16), p<0.02, respectively.

CONCLUSIONS

Immunization of pregnant women with Tdap between 27-30(+6) weeks was associated with the highest umbilical cord GMCs of IgG to PT and FHA compared with immunization beyond 31 weeks gestation. Further research should be conducted to reaffirm these finding in order to promote an optimal pertussis controlling policy.

The induction of breast milk pertussis specific antibodies following gestational tetanus-diphtheria-acellular pertussis vaccination

BACKGROUND

Center for Disease Control and Prevention recommends vaccination of pregnant women with tetanus-diphtheria-acellular pertussis (Tdap).

AIM

To measure pertussis specific antibodies, total protein and their ratio in breast milk following gestational Tdap vaccination.

METHODS

Women who received Tdap after the 20th week of pregnancy were recruited and unvaccinated women served as controls. Breast milk total protein, immunoglobulin A (IgA) to pertussis toxin (PT), filamentous hemagglutinin (FHA) and immunoglobulin G (IgG) to PT, FHA and pertactin (PRN) were measured. To overcome the dilution that occurs in the transition from colostrum to mature breast milk, we calculated pertussis specific antibody to total protein ratio.

RESULTS

Pertussis specific IgA was the predominant pertussis immunoglobulin in the colostrum of Tdap vaccinated women with the geometric mean concentrations (GMCs) of IgA to FHA higher than for IgA to PT, 24.12 ELISA units/milliliter (EU/mL) vs. 8.18EU/mL, respectively, p<0.004. There were differences between the vaccinated women and controls in the GMCs of IgA to FHA and IgG to PRN in the colostrum, 24.12EU/mL vs. 6.52EU/mL, p=0.01 and 2.46EU/mL vs. <0.6EU/mL, p=0.03, respectively. The GMCs of total protein showed significant decline over 8 weeks in the vaccinated women and controls, p<0.004. Among vaccinated women, there was significant decline in the GMCs of IgA to PT and FHA over 8 weeks, p<0.001. The geometric mean ratio of IgA to FHA to total protein also declined significantly over 8 weeks in the vaccinated women, p<0.01, demonstrating a true decrease, however, pertussis IgA was measurable at 8 weeks.

CONCLUSIONS

Select colostrum pertussis antibody levels were significantly higher among women vaccinated with Tdap during pregnancy compared with unvaccinated women. Among vaccinated women, maximal levels of pertussis specific IgA were in the colostrum but still detected at 8 weeks. Lactation may augment infant's protection against pertussis.

Legionella pneumophila and Pneumocystis jirovecii coinfection in an infant treated with adrenocorticotropic hormone for infantile spasm: case report and literature review

We describe an 8-month-old infant with infantile spasms treated with adrenocorticotropic hormone (ACTH) who presented with fatal Legionella pneumophila and Pneumocystis jirovecii infection. Emphasis is placed on the ensuing immunosuppression and infectious sequelae of ACTH therapy. Given that ACTH therapy may increase the risk of fatal infection, patients undergoing such treatment should be closely monitored, with particular attention paid to the functioning of the immune system.

[Genital ulcers--what's new?]

The most common infectious causes of genital ulcers are herpes simplex virus and syphilis. However, mixed infections can occur and genital ulcer may increase the risk of acquiring human immunodeficiency virus. Although the history and physical examination can narrow the differential diagnosis, there is a need for initial routine laboratory testing for the most common pathogens that includes: for syphilis: serologic screening and dark field examination of the lesion; for herpes simplex virus: serology, vial culture and/or polymerase chain reaction. Human immunodeficiency testing is mandatory. Recently, some clinical laboratories adapted the reverse screening algorithm for syphilis (initial treponemal test, and, if positive, followed by non-treponemal test) that may potentially lead to overtreatment. Early and prompt therapy may decrease the risk of transmission of the infectious agent to others. This article reviews the infectious pathogens causing genital ulcers, their unique clinical manifestation, diagnosis and treatment.

Beyond "safe sex"--can we fight adolescent pelvic inflammatory disease?

Pelvic inflammatory disease (PID) is a common disorder affecting sexually active adolescents. The Centers for Disease Control and Prevention (CDC) and European CDC report Chlamydia trachomatis as the most common sexually transmitted infection and one of the main etiological agents causing PID. C. trachomatis' and PID's high prevalence may be attributed to multiple factors including high-risk sexual behaviors, sensitive laboratory diagnostics (polymerase chain reaction), and the introduction of chlamydia screening programs. The pathogenesis of C. trachomatis infection is complex with recent data highlighting the role of toll-like receptor 2 and four in the mediation of the inflammatory cascade. The authors review the etiology of the disease, explore its pathogenesis, and discuss a variety of strategies that may be implemented to reduce the prevalence of C. trachomatis including: (a) behavioral risk reduction, (b) effective screening of asymptomatic females, (c) targeted male screening, (d) implementation of a sensitive, rapid, self-administered point-of-care testing, and (e) development of an effective vaccine.

Toll-like receptor-4 expression in infants with pertussis infection

PURPOSE

Our aim was to evaluate the expression of Toll-like receptor-4 (TLR-4) and the level of interferon-gamma (IFN-γ) and interleukin-10 (IL-10) in young infants infected by Bordetella pertussis and B. parapertussis.

METHODS

Twenty-two infants under the age of 3.5 months with the clinical suspicion of pertussis were enrolled in the study. Nasopharyngeal secretions were obtained for laboratory testing, and blood samples were obtained for flow cytometry and cytokine level analysis.

RESULTS

Six infants had positive PCR results for pertussis; the other 16 infants had infections attributable to another causal agent and were used as the control group. The mean fluorescence index, used as a measure of TLR-4 expression by monocytes, was significantly lower in infants with pertussis than in the control group infants (34.32 ± 18.58 vs. 63.14 ± 28, respectively; p = 0.041). The serum IFN-γ level was also significantly lower in infants with pertussis than in the control group patients (0.41 ± 0.58 vs. 1.36 ± 1.87, respectively; p = 0.04). No differences were found in the levels of IL-10.

CONCLUSIONS

Based on these results, we suggest that TL4 expression by monocytes and serum INF-γ levels are lower in infants with positive PCR results for pertussis than in infants with a non-pertussis upper respiratory tract infection.

Elevated serum total IgE--a potential marker for severe chronic urticaria

BACKGROUND

Elevated IgE levels in patients with chronic urticaria have been noted previously, but the significance of these findings has not been appreciated.

OBJECTIVE

To measure the IgE levels in such patients and to examine the relationship between these levels and urticarial severity, autologous serum skin test, anti-thyroid antibodies and duration.

METHODS

Serum total IgE levels from 203 patients with chronic urticaria were measured and compared with nonatopic individuals. Additionally, patients were assessed for urticarial severity, the presence of autologous serum skin test and anti-thyroid antibodies.

RESULTS

Of the chronic urticaria patients, 47 (23.2%) were classified as mild, whereas 67 (33%) were classified as having moderate and 89 (43.8%) as having severe chronic urticaria. Total IgE levels were elevated, above 175 U/ml, in 69/203 (34%) of patients, compared with 7/81 (8.6%) of healthy controls (p < 0.001). A significant association between increased total IgE and chronic urticaria severity was found. Whereas 93% of patients with increased level of total IgE suffered from moderate-to-severe chronic urticaria, this was observed in only 69% of patients with normal IgE (p < 0.0001). Autologous serum skin test and anti-thyroid antibodies were positive in 59/163 (36%) and 28/189 (15%) patients, respectively. A significant association between increased total IgE levels and the presence of autologous serum skin test, anti-thyroid antibodies and urticarial duration lasting more than 25 months (p < 0.0001, p < 0.0001 and p = 0.021, respectively) was also detected.

CONCLUSIONS

Total serum IgE levels are frequently elevated in patients with chronic urticaria and these are associated with disease severity and duration.

[Adult pertussis poses a severe risk for infants]

In Israel, there have been increasing reports of Bordetella pertussis infection among adolescents and adults, but the peak incidence and highest mortality occur among infants. The authors report four cases involving the likely transmission of pertussis from parents to their offspring in two hospitals in Israel. The adoption of proper infection control measures and targeted screening of parents may reduce the potential risk for such transmission.

The role of T regulatory cells in human sepsis

It is well-known that septic shock undermines immune homeostasis by inducing an initial intense systemic inflammatory response that is rapidly followed by a negative feedback of anti-inflammatory process. This secondary immunoparalysis state is characterized by decreased phagocytic cells, T cells, natural killer cells and B cells function and proinflammatory cytokine release. This persistence of immunoparalysis increased the risk for fatal outcome. In recent studies it was found that following the onset of septic shock, a relative increase in T regulatory cells number and suppressive function appears and makes them an important participant in the inhibition of immune responsiveness during sepsis. Consequently, a question emerging from these findings concerns the degree to which the manipulation of T regulatory cells might improve the outcome of patients with sepsis. Preliminary studies in animal models suggest that more work is needed to understand the conditions under which such a therapy may be effective.

Abnormal spirometry in children with persistent allergic rhinitis due to mite sensitization: the benefit of nasal corticosteroids

Inflammatory processes affecting nasal and bronchial mucosa are similar in nature. The purpose of this study was to examine whether children with perennial allergic rhinitis, without underlying asthma, have impaired pulmonary function. We also investigated whether nasal corticosteroids and loratidine would improve the pulmonary function tests of those children with impaired lung function. Fifty subjects with moderate/severe persistent allergic rhinitis due to exclusively dust mite sensitization and no past medical history suggestive of asthma were assessed. The control group consisted of 26 matched healthy subjects. Subjects with airway obstruction, as detected by forced expiratory volume/1 s (FEV1) or forced expiratory flow from 25/% to 75% (FEF(25-75)) values <80% of those predicted, were treated with loratidine, once a day for 10 days, and daily nasal budesonide for 3 months. We found that 11 of 50 patients (22%) with perennial allergic rhinitis had impaired pulmonary function (FEF(25-75) values <80%), compared to 1/26 (3.8%) of the control group (p < or = 0.05). Reversibility was observed in 9/11 (81.8%), mean 24.7% +/- 10.3%. Within 3 months of treatment, 7/10 had FEF(25-75) > 80% of their predicted values as well as significant improvements in their FEV1 (p = 0.04), and FEV1/FVC (p = 0.04). We conclude that a substantial proportion of children with perennial allergic rhinitis have diminished FEF (25-75) values and reversible airway obstruction. Nasal corticosteroids improve the pulmonary function tests of these children with impaired lung function.

Pertussis is under diagnosed in infants hospitalized with lower respiratory tract infection in the pediatric intensive care unit

BACKGROUND

To determine the rate of pertussis in infants aged <1 year hospitalized at the pediatric intensive care unit (PICU) with lower respiratory tract infection (LRTI) and to characterize the clinical aspects of these patients.

MATERIAL/METHODS

Infants <12 months hospitalized with LRTI in the PICU were identified retrospectively. Demographic, clinical and laboratory data were obtained. Stored nasopharyngeal washes (NPW) were tested by polymerase chain reaction (PCR) for the pertussis toxin gene (ptxA) and insertion element IS481 sequences.

RESULTS

Eleven of seventy-four (15%) NPW were positive for pertussis, none of them was clinically suspected. Of the positive patients, 82% suffered from paroxysmal cough vs. 32% of the negative patients and from prolonged cough, 45.5% vs. 8%, respectively (P<0.01). Thirty (41%) patients needed mechanical ventilation with no differences between positive and negative pertussis patients. Infiltrates in x-rays were more common among pertussis negative than among pertussis positive patients, 29% vs. 0% (P=0.05).

CONCLUSIONS

Lower respiratory tract infections caused by pertussis are a more frequent cause of admission to the PICU than generally recognized. Patient's history with paroxysmal cough suggests the possibility of pertussis and the lack of whooping cough does not rule out pertussis. Pediatricians should be aware of the limitations of their diagnostic tools when ruling out pertussis especially in infants with a diagnosis of bronchiolitis. Using new diagnostic methods add considerably to the sensitivity of pertussis diagnosis in PICU and PCR techniques should be used routinely, at least in a PICU setting.

Increased susceptibility of cord blood B lymphocytes to undergo spontaneous apoptosis

In this study, we compared the rate of spontaneous apoptosis of B cells from umbilical cord blood with adult B cells and assessed the role of Bcl-2, CD5, interleukin (IL)-4 and B cell-activating factor in B cell spontaneous apoptosis. We found that spontaneous apoptosis of cultured B cells, as assessed by utilizing annexin-V binding, was significantly higher in cord blood than in healthy adult individuals (77.5; 95 CI, 73.5-81.5 versus 59.2; 95 CI, 54-64, respectively, P < 0.0001) and further confirmed by 4' 6-diamidino-2-phenylindole, dihydrochloride (DAPI) staining. Whereas the expression of B cell-activating factor from the tumour necrosis factor family (BAFF) receptor mRNA was similar in B cells from adults and cord blood, we detected lower levels of circulating BAFF in the serum of cord blood (0.68 +/- 0.13 ng versus 1.83 +/- 0.54 ng, P = 0.01). The latter may explain, in part, our observation of lower levels of mean fluorescence intensity of Bcl-2 in cord B cells compared with adults (1.6 +/- 0.9 versus 2.85 +/- 1.3, P = 0.033). CD19(+) CD5(+) B cells from cord blood underwent a lower rate of apoptosis in comparison to CD19(+) CD5(-) B cells (25.1 +/- 9.3%versus 58.5 +/- 12.5%, P < 0.0001). This pattern of sensitivity was comparable in adult blood (15 +/- 5.5%versus 22.7 +/- 9.3%, P = 0.01). Nevertheless, the rate of apoptosis was higher in CD19(+) CD5(+) from cord blood compared to CD19(+) CD5(+) from adults (25.1 +/- 9.3%versus 15 +/- 5.5%, P = 0.0013). The addition of rIL-4 (10 u/ml) to cultured cells decreased B cell apoptosis in a similar fashion in both cord and adults blood. This rescue was strengthened when BAFF (100 microg/ml) was further added. Thus, alterations in Bcl-2 or serum BAFF level may explain the increased rate of cord blood B cell apoptosis.

The return of pertussis: who is responsible? What can be done?

The Israel Ministry of Health's epidemiology department reported a record number of 1564 new pertussis cases in 2004. This brings the incidence rate to 23 per 100,000 population, indicating a marked increase in the prevalence of pertussis, from 1-3/100,000 in 1998, 9 in 2001, to 14 in 2003. The rate of atypical pertussis presentations in vaccinated patients, the decline in pertussis immunity post-vaccination, and the decreased awareness of potential infections in the adult population make the diagnosis of pertussis difficult and contribute to the rising incidence. In this article we review the current literature in order to increase awareness of the occurrence of pertussis in children as well as adults, discuss the laboratory diagnostic methods being used, and report the currently recommended means of treating the disease.