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Wang C, Zhang H, Zhang Y, Xu L, Miao M, Yang H, Liu Y, He S, Pang L. Analysis of clinical characteristics of severe pertussis in infants and children: a retrospective study. BMC Pediatr 2021; 21:65. [PMID: 33546645 PMCID: PMC7863367 DOI: 10.1186/s12887-021-02507-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 01/14/2021] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The incidence of pertussis shows an increasing trend in recent years, but some clinicians often lack sufficient understanding of the clinical characteristics and risk factors for severe pertussis, and more effective measures should be taken to reduce the incidence and mortality of pertussis in young infants METHODS: A retrospective study was conducted, and 184 infants and children with pertussis who had been hospitalized in the Department of Pediatrics of Beijing Ditan Hospital affiliated with Capital Medical University from January 2016 to December 2017 were included. Clinical data of the patients were collected and the clinical characteristics were statistically analyzed RESULTS: Among the 184 patients, 41.85% were infants < 3 months of age, and 65.22% of the total patients were not vaccinated against pertussis. There were 22 critically ill children, among whom 4 died, and compared with mild cases, they had a higher proportion of children younger than 3 months of age and infants not vaccinated against pertussis (63.64% vs. 38.89% and 100% vs. 60.49%, respectively); a higher proportion of children with severe pneumonia (100% vs. 0%); higher leukocyte count(× 109/L , 35.80 ± 20.53 vs 19.41 ± 8.59); and a higher proportion of children with severe hyperleukocytosis (18.18% vs. 0%, respectively) (P<0.05) CONCLUSIONS: 1. Infants aged <3 months not vaccinated for pertussis appear more likely to become infected and have more severe disease. 2. Severe pneumonia and hyperleukocytosis are the main mechanisms underlying severe pertussis.
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Affiliation(s)
- Caiying Wang
- Department of Pediatrics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Huimin Zhang
- Department of Pediatrics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yanlan Zhang
- Department of Pediatrics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Lin Xu
- Department of Pediatrics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Min Miao
- Department of Pediatrics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Hongling Yang
- Department of Pediatrics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yuhuan Liu
- Department of Pediatrics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Shuxin He
- Department of Pediatrics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Lin Pang
- Department of Pediatrics, Beijing Ditan Hospital, Capital Medical University, Beijing, China.
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2
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Liu C, Yang L, Cheng Y, Xu H, Xu F. Risk factors associated with death in infants <120 days old with severe pertussis: a case-control study. BMC Infect Dis 2020; 20:852. [PMID: 33198647 PMCID: PMC7668018 DOI: 10.1186/s12879-020-05535-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 10/21/2020] [Indexed: 11/13/2022] Open
Abstract
Background and purpose Pertussis is a serious infectious disease in young infants, and severe cases frequently cause death. Our study explored risk factors for death from severe pertussis. Method A case-control study of infants with severe pertussis admitted to the paediatric intensive care unit (PICU) in the Children’s Hospital of Chongqing Medical University, China, from January 1, 2013, to June 30, 2019, was conducted. Pertussis was confirmed by clinical features and laboratory examinations. Severe pertussis was defined as patients with pertussis resulting in PICU admission or death. To understand the risk factors for death, we compared fatal and nonfatal cases of severe pertussis in infants aged < 120 days by collecting clinical and laboratory data. Results The participants included 63 infants < 120 days of age with severe pertussis. Fifteen fatal cases were confirmed and compared with 44 nonfatal severe pertussis cases, Four patients with termination of treatment were excluded. In the univariate analysis, the risk factors associated with death included apnoea (P = 0.001), leukocytosis (white blood cell (WBC) count≥30 × 109/L (P = 0.001) or ≥ 50 × 109/L (P = 0)), highest lymphocyte count (P = 0), pulmonary hypertension (P = 0.001), and length of PICU stay (P = 0.003). The multivariate analysis revealed that apnoea (OR 23.722, 95%CI 2.796–201.26, P = 0.004), leukocytosis (OR 63.708, 95%CI 3.574–1135.674, P = 0.005) and pulmonary hypertension (OR 26.109, 95%CI 1.800–378.809, P = 0.017) were significantly associated with death. Conclusion Leukocytosis and pulmonary hypertension exhibited the greatest associations with death in infants with severe pertussis admitted to the PICU. Vaccination is still the most effective protection method against pertussis.
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Affiliation(s)
- Cong Liu
- Department of Infectious Diseases, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China.,National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China
| | - Lin Yang
- National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China.,Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China
| | - Yuwei Cheng
- National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China.,Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China
| | - Hongmei Xu
- Department of Infectious Diseases, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China.,National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China
| | - Feng Xu
- National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, China. .,Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China. .,Department of Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China.
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3
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Epidemiology and Outcome of Hospitalized Infants With Pertussis. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2019. [DOI: 10.1097/ipc.0000000000000780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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4
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Machado MB, Passos SD. SEVERE PERTUSSIS IN CHILDHOOD: UPDATE AND CONTROVERSY - SYSTEMATIC REVIEW. ACTA ACUST UNITED AC 2019; 37:351-362. [PMID: 31116241 PMCID: PMC6868560 DOI: 10.1590/1984-0462/;2019;37;3;00006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 04/29/2018] [Indexed: 01/12/2023]
Abstract
Objective: Through a systematic review, this essay aimed at revising the concepts of
severe pertussis, updating the epidemiology,
pathophysiology, clinical presentation, antibiotic therapy and auxiliary
therapeutic options for symptomatology and complications. Data sources: This review considered publications from the last 30years in the databases US
National Library of Medicine (PubMed), Scientific Electronic Library Online
(SciELO), Literatura Latino-americana e do Caribe em Ciências da Saúde
(LILACS), Cochrane, Google Scholar, as well as protocols of the Ministry of
Health and recommendations of the Centers for Disease Control and
Prevention, related to childhood pertussis (whooping
cough), with emphasis on its severe form. This research was based on
keywords derived from the terms “pertussis”,
“azithromycin”, “antitussives”, “leukocyte reduction” in Portuguese and
English. Duplicate studies and those with unavailable full-text were
excluded. Data synthesis: Among 556 records found, 54 were selected for analysis.
Pertussis, as a reemerging disease, has affected all
age groups, evidencing the transient immunity conferred by infection and
vaccination. Severe cases occur in neonates and infants, with secondary
viral and bacterial complications and malignant pertussis,
a longside hyperleukocytosis, respiratory failure and shock. Macrolides
continue to be the chosen antibiotics, while antitussives for coughing
remain without efficacy. The prompt treatment in Intensive Care Units
improved the prognostic in severe cases, and transfusion was promising among
procedures for leukoreduction. Conclusions: Approaching severe pertussis in childhood remains a challenge for diagnostic
and therapy, as the available therapeutic options are still unsatisfactory.
Strategies of prevention are expected to reduce the occurrence of severe
cases, while new studies should confirm the role of auxiliary therapies.
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5
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Wei XM, Yang H, Lei M, Deng JK. [Blood exchange transfusion for treatment of severe pertussis in an infant]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2019; 21:214-217. [PMID: 30907342 PMCID: PMC7389349 DOI: 10.7499/j.issn.1008-8830.2019.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 02/03/2019] [Indexed: 06/09/2023]
Affiliation(s)
- Xue-Mei Wei
- Department of Infectious Disease, Shenzhen Children's Hospital, Shenzhen, Guangdong 518038, China
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Abstract
BACKGROUND Pertussis in young infants is a unique, severe, afebrile, cough illness that is frequently fatal. METHODS All pertussis cases ≤120 days of age admitted to a pediatric intensive care unit in California between October 1, 2013, and April 25, 2015, were evaluated. RESULTS Of 100 pertussis patients ≤120 days of age admitted to pediatric intensive care unit, there were 5 deaths. The white blood cell counts in the fatal cases were significantly higher than in the nonfatal cases. Thirty-four percent of patients were intubated, 18% received inotropic and/or vasoactive support, 22% received steroid, 4% received extracorporal membrane oxygenation, and 3% underwent exchange blood transfusion. The median age at the time of illness onset in the patients who died was 23 days. CONCLUSIONS These data, as well as data from previous California studies, suggest updated strategies for the management of severe pertussis. These include perform serial white blood cell counts, treat all presumptive cases with azithromycin, evaluate for pulmonary hypertension, intubate and administer oxygen for apneic episodes and administer inotropic/vasoactive agents for cardiogenic shock. Do not administer steroids or nitric oxide. Criteria for exchange blood transfusion therapy for leukocytosis with lymphocytosis are suggested.
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7
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Extracorporeal Membrane Oxygenation for Pertussis: Predictors of Outcome Including Pulmonary Hypertension and Leukodepletion. Pediatr Crit Care Med 2018; 19:254-261. [PMID: 29319632 DOI: 10.1097/pcc.0000000000001454] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The recent increase of pertussis cases worldwide has generated questions regarding the utility of extracorporeal membrane oxygenation for children with pertussis. We aimed to evaluate factors associated with extracorporeal membrane oxygenation outcome. DESIGN The study was designed in two parts: a retrospective analysis of the Extracorporeal Life Support Organization Registry to identify factors independently linked to outcome, and an expanded dataset from individual institutions to examine the association of WBC count, pulmonary hypertension, and leukodepletion with survival. SETTING Extracorporeal Life Support Organization Registry database from 2002 though 2015, and contributions from 19 international centers. PATIENTS Two hundred infants from the Extracorporeal Life Support Organization Registry and expanded data on 73 children. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 200 infants who received extracorporeal membrane oxygenation for pertussis, only 56 survived (28%). In a multivariable logistic regression analysis, the following variables were independently associated with increased chance of survival: older age (odds ratio, 1.43 [1.03-1.98]; p = 0.034), higher PaO2/FIO2 ratio (odds ratio, 1.10 [1.03-1.17]; p = 0.003), and longer intubation time prior to the initiation of extracorporeal membrane oxygenation (odds ratio, 2.10 [1.37-3.22]; p = 0.001). The use of vasoactive medications (odds ratio, 0.33 [0.11-0.99]; p = 0.047), and renal neurologic or infectious complications (odds ratio, 0.21 [0.08-0.56]; p = 0.002) were associated with increased mortality. In the expanded dataset (n =73), leukodepletion was independently associated with increased chance of survival (odds ratio, 3.36 [1.13-11.68]; p = 0.03) while the presence of pulmonary hypertension was adverse (odds ratio, 0.06 [0.01-0.55]; p = 0.01). CONCLUSIONS The survival rate for infants with pertussis who received extracorporeal membrane oxygenation support remains poor. Younger age, lower PaO2/FIO2 ratio, vasoactive use, pulmonary hypertension, and a rapidly progressive course were associated with increased mortality. Our results suggest that pre-extracorporeal membrane oxygenation leukodepletion may provide a survival advantage.
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8
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Norgan AP, Juskewitch JE, Pritt BS, Winters JL. The use of cytapheresis in the treatment of infectious diseases. J Clin Apher 2018; 33:529-537. [PMID: 29488237 DOI: 10.1002/jca.21620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 01/08/2018] [Accepted: 02/16/2018] [Indexed: 11/11/2022]
Abstract
Cytapheresis (removal of cellular blood components) has been employed for treatment of infectious diseases since the 1960s. Techniques have included thrombocytapheresis (buffy coat apheresis) for loiasis, erythrocytapheresis for malaria and babesiosis, and leukocytapheresis for pertussis-associated lymphocytosis. Published data on these applications is largely limited to case level data and small observational studies; as such, recommendations for or against the use of cytapheresis in the treatment of infections have been extrapolated from these limited (and at times flawed) data sets. Consequently, utilization of cytapheresis in many instances is not uniform between institutions, and typically occurs at the discretion of treating medical teams. This review revisits the existing literature on the use of cytapheresis in the treatment of four infections (loasis, malaria, babesiosis, and pertussis) and examines the rationale underlying current treatment recommendations concerning its use.
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Affiliation(s)
- Andrew P Norgan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Justin E Juskewitch
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Bobbi S Pritt
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.,Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota
| | - Jeffrey L Winters
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.,Division of Transfusion Medicine, Mayo Clinic, Rochester, Minnesota
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9
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Canter MO, Daniels J, Bridges BC. Adjunctive Therapies During Extracorporeal Membrane Oxygenation to Enhance Multiple Organ Support in Critically Ill Children. Front Pediatr 2018; 6:78. [PMID: 29670870 PMCID: PMC5893897 DOI: 10.3389/fped.2018.00078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/14/2018] [Indexed: 12/17/2022] Open
Abstract
Since the advent of extracorporeal membrane oxygenation (ECMO) over 40 years ago, there has been increasing interest in the use of the extracorporeal circuit as a platform for providing multiple organ support. In this review, we will examine the evidence for the use of continuous renal replacement therapy, therapeutic plasma exchange, leukopheresis, adsorptive therapies, and extracorporeal liver support in conjunction with ECMO.
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Affiliation(s)
- Marguerite Orsi Canter
- Division of Pediatric Critical Care, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Jessica Daniels
- Division of Pediatric Critical Care, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Brian C Bridges
- Division of Pediatric Critical Care, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, United States
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10
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Maitre G, Schaffner D, Natterer J, Longchamp D, Ferry T, Diezi M, Di Bernardo S, Perez MH, Amiet V. Leukemoid Reaction in Infant Pertussis: Is There a Place for Hydroxyurea? A Case Report. Front Pediatr 2018; 6:261. [PMID: 30356838 PMCID: PMC6190881 DOI: 10.3389/fped.2018.00261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 09/03/2018] [Indexed: 01/18/2023] Open
Abstract
A 73-days old infant of 34 weeks' gestation was hospitalized with a co-infection of respiratory syncytial virus (RSV) and Bordetella pertussis (BP). She required invasive ventilation for 9 days in the context of malignant pertussis with persistent hypoxemia and hypercapnia secondary to a leukemoid reaction. Despite an increase of white blood cell (WBC) count up to 70 G/L and ensuing pulmonary hypertension, no hemodynamic compromise occurred. Without clear indication for leukapheresis nor exchange transfusion, an off-label treatment with hydroxyurea was given for 5 days with gradual decrease of WBC count, without any complication and hospital discharge on day 29. To our knowledge, no effective therapy for malignant pertussis has been described in the literature and complications are frequent with leukoreduction procedures. We discuss an alternative to invasive procedures in young infants to fulfill the need to decrease rapidly leukocyte counts in a leukemoid reaction associated with Bordetella pertussis infection. To our knowledge, hydroxyurea has never been used in malignant pertussis but is a well-known medication for oncologic and hematologic diseases such as acute myeloid leukemia or sickle cell anemia. Its effects in this setting are not well understood but the positive outcome in our patient supports the need for further studies.
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Affiliation(s)
- Guillaume Maitre
- Pediatric Intensive Care Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - Damien Schaffner
- Pediatric Intensive Care Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - Julia Natterer
- Pediatric Intensive Care Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - David Longchamp
- Pediatric Intensive Care Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - Thomas Ferry
- Pediatric Intensive Care Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - Manuel Diezi
- Pediatric Onco-Hematology Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - Stefano Di Bernardo
- Pediatric Cardiology Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - Marie-Hélène Perez
- Pediatric Intensive Care Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - Vivianne Amiet
- Pediatric Intensive Care Unit, Lausanne University Hospital, Lausanne, Switzerland
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11
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Abstract
Pertussis is a highly infectious vaccine-preventable cough illness that continues to be a significant source of morbidity and mortality around the world. The majority of human illness is caused by Bordetella pertussis, and some is caused by Bordetella parapertussis. Bordetella is a Gram-negative, pleomorphic, aerobic coccobacillus. In the past several years, even countries with high immunization rates in early childhood have experienced rises in pertussis cases. Reasons for the resurgence of reported pertussis may include molecular changes in the organism and increased awareness and diagnostic capabilities, as well as lessened vaccine efficacy and waning immunity. The most morbidity and mortality with pertussis infection is seen in infants too young to benefit from immunization. Severe infection requiring hospitalization, including in an intensive care setting, is mostly seen in those under 3 months of age. As a result, research and public health actions have been aimed at better understanding and reducing the spread of Bordetella pertussis. Studies comparing the cost benefit of cocooning strategies versus immunization of pregnant women have been favorable towards immunizing pregnant women. This strategy is expected to prevent a larger number of pertussis cases, hospitalizations, and deaths in infants <1 year old while also being cost-effective. Studies have demonstrated that the source of infection in infants usually is a family member. Efforts to immunize children and adults, in particular pregnant women, need to remain strong.
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12
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Kilgore PE, Salim AM, Zervos MJ, Schmitt HJ. Pertussis: Microbiology, Disease, Treatment, and Prevention. Clin Microbiol Rev 2016; 29:449-86. [PMID: 27029594 PMCID: PMC4861987 DOI: 10.1128/cmr.00083-15] [Citation(s) in RCA: 226] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Pertussis is a severe respiratory infection caused by Bordetella pertussis, and in 2008, pertussis was associated with an estimated 16 million cases and 195,000 deaths globally. Sizeable outbreaks of pertussis have been reported over the past 5 years, and disease reemergence has been the focus of international attention to develop a deeper understanding of pathogen virulence and genetic evolution of B. pertussis strains. During the past 20 years, the scientific community has recognized pertussis among adults as well as infants and children. Increased recognition that older children and adolescents are at risk for disease and may transmit B. pertussis to younger siblings has underscored the need to better understand the role of innate, humoral, and cell-mediated immunity, including the role of waning immunity. Although recognition of adult pertussis has increased in tandem with a better understanding of B. pertussis pathogenesis, pertussis in neonates and adults can manifest with atypical clinical presentations. Such disease patterns make pertussis recognition difficult and lead to delays in treatment. Ongoing research using newer tools for molecular analysis holds promise for improved understanding of pertussis epidemiology, bacterial pathogenesis, bioinformatics, and immunology. Together, these advances provide a foundation for the development of new-generation diagnostics, therapeutics, and vaccines.
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Affiliation(s)
- Paul E Kilgore
- Department of Pharmacy Practice, Eugene Applebaum Collage of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Abdulbaset M Salim
- Department of Pharmacy Practice, Eugene Applebaum Collage of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Marcus J Zervos
- Division of Infectious Diseases, Department of Internal Medicine, Henry Ford Health System and Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Heinz-Josef Schmitt
- Medical and Scientific Affairs, Pfizer Vaccines, Paris, France Department of Pediatrics, Johannes Gutenberg-University, Mainz, Germany
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13
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Salim AM, Liang Y, Kilgore PE. Protecting Newborns Against Pertussis: Treatment and Prevention Strategies. Paediatr Drugs 2015; 17:425-41. [PMID: 26542059 DOI: 10.1007/s40272-015-0149-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Pertussis is a potentially severe respiratory disease, which affects all age groups from young infants to older adults and is responsible for an estimated 195,000 deaths occurred globally in 2008. Active research is ongoing to better understand the pathogenesis, immunology, and diagnosis of pertussis. For diagnosis, molecular assays (e.g., polymerase chain reaction) for detection of Bordetella pertussis have become more widely available and support improved outbreak detection. In children, pertussis vaccines have been incorporated into routine immunization schedules and deployed for pertussis outbreak control. Lower levels of vaccine coverage are now being observed in communities where vaccine hesitancy is rising. Additionally, recognition that newborn babies are at risk of pertussis in the USA and UK has led to recommendations to immunize pregnant women. Among adolescents and older adults in the USA, Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular pertussis (Tdap) Vaccines are recommended, but substantial individual- and system-level barriers exist that will make achieving national Healthy People 2020 targets for immunization challenging. Current antimicrobial regimens for pertussis are focused on reducing the severity of disease, reducing rates of sequelae, and minimizing transmission of infection to susceptible individuals. Continued surveillance for pertussis will be important to identify opportunities for reducing young infants' exposure and reducing the impact of outbreaks among school-aged children. Laboratory-based surveillance for newly emerging strains of B. pertussis will be important to identify strains that may evade protection elicited by currently available vaccines. Efforts to develop new-generation pertussis vaccines should be considered now in anticipation of vaccine development programs, which may require ten or more years to deliver a licensed vaccine.
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Affiliation(s)
- Abdulbaset M Salim
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA.
| | - Yan Liang
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA. .,Institute of Medical Biology, Chinese Academy of Medical Science, Peking Union Medical College, Kunming, China.
| | - Paul E Kilgore
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA.
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14
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Chantreuil J, Fakhri N, Labarthe F, Saliba E, Favrais G. [Malignant pertussis and exchange transfusion]. Arch Pediatr 2014; 22:84-7. [PMID: 25466784 DOI: 10.1016/j.arcped.2014.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 10/15/2014] [Indexed: 11/16/2022]
Abstract
CASE REPORT Malignant pertussis is a critical clinical state associated with fatal outcome in 70% of cases. The severity criteria are a lung infection with pulmonary hypertension and hyperleukocytosis usually above 50 G/L. We report the case of a 2.5-month-old girl hospitalized with critical pertussis in a pediatric intensive care unit. She had acute respiratory distress syndrome with pulmonary hypertension complicated by a bacterial secondary infection with Enterobacter cloacae managed by high-frequency oscillatory ventilation associated with pulmonary vasodilatation therapy. In the absence of clinical improvement and before considering extracorporeal life support, exchange transfusion was performed at day 9 to reduce hyperleukocytosis at 70 G/L. Exchange transfusion was successfully performed with a reduction of leukocytes to under 40 G/L followed by steady improvement of pulmonary function. Weaning from mechanical ventilation and discharge took place at day 23 and 38, respectively. COMMENTS Exchange transfusion should be considered in infants suffering from malignant pertussis with extreme leukocytosis before hemodynamic failure to improve the survival prognosis.
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Affiliation(s)
- J Chantreuil
- Réanimation pédiatrique et néonatologie, hôpital Clocheville, CHRU de Tours, 49, boulevard Béranger, 37000 Tours, France.
| | - N Fakhri
- Réanimation pédiatrique et néonatologie, hôpital Clocheville, CHRU de Tours, 49, boulevard Béranger, 37000 Tours, France; Faculté de médecine de Tours, université François-Rabelais, 37000 Tours, France
| | - F Labarthe
- Médecine pédiatrique, hôpital Clocheville, CHRU de Tours, 37000 Tours, France; Inserm U1069, faculté de médecine de Tours, université François-Rabelais, 37000 Tours, France
| | - E Saliba
- Réanimation pédiatrique et néonatologie, hôpital Clocheville, CHRU de Tours, 49, boulevard Béranger, 37000 Tours, France; Inserm U930, faculté de médecine de Tours, université François-Rabelais, 37000 Tours, France
| | - G Favrais
- Réanimation pédiatrique et néonatologie, hôpital Clocheville, CHRU de Tours, 49, boulevard Béranger, 37000 Tours, France; Inserm U930, faculté de médecine de Tours, université François-Rabelais, 37000 Tours, France
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15
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Sloan SR, Andrzejewski C, Aqui NA, Kiss JE, Krause PJ, Park YA. Role of therapeutic apheresis in infectious and inflammatory diseases: Current knowledge and unanswered questions. J Clin Apher 2014; 30:259-64. [PMID: 25351167 DOI: 10.1002/jca.21370] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 10/14/2014] [Indexed: 11/06/2022]
Abstract
Apheresis can remove pathogens and mediators that contribute to pathogenic inflammatory responses in diseases not generally considered to be "Hematologic." Erythrocytapheresis can remove intracellular pathogens such as Babesiosis. Plasmapheresis can remove mediators of the inflammatory response in conditions such as sepsis, chronic autoimmune urticaria and malignant pertussis. Leukapheresis can remove potentially harmful leukocytes in Crohn's Disease and malignant pertussis. While apheresis can remove all of these substances, the clinical efficacy and pathophysiologic changes that occur during apheresis in these conditions are largely unknown. Hence, the clinical utility of apheresis in these conditions is largely unknown and research in these areas has the potential to benefit many patients with a variety of diseases.
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Affiliation(s)
- Steven R Sloan
- Blood Bank Medical Director, Department of Laboratory Medicine, Boston Children's Hospital, Boston, Massachusetts.,Associate Professor of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Chester Andrzejewski
- Medical Director Transfusion and Apheresis Medicine Services, Baystate Medical Center, Springfield, Massachusetts.,Assistant Professor of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, Massachusetts
| | - Nicole A Aqui
- Assistant Professor of Clinical Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph E Kiss
- Associate Professor of Medicine, University of Pittsburgh, Pennsylvania.,Department of Medicine, University of Pittsburgh, Pennsylvania.,Division of Hematology-Oncology, University of Pittsburgh, Pennsylvania.,The Institute for Transfusion Medicine, Pittsburgh, Pennsylvania
| | - Peter J Krause
- Senior Research Scientist in Epidemiology, Medicine and Pediatrics, Lecturer in Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Yara A Park
- Assistant Professor, Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina
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16
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Ulloa-Gutierrez R, Avila-Aguero ML. Pertussis in Latin America: current situation and future vaccination challenges. Expert Rev Vaccines 2014; 7:1569-80. [DOI: 10.1586/14760584.7.10.1569] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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17
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Murray et al (J Pediatric Infect Dis Soc 2013; 2:1-6). J Pediatric Infect Dis Soc 2013; 2:187-8. [PMID: 26619469 DOI: 10.1093/jpids/pit029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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18
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Murray EL, Nieves D, Bradley JS, Gargas J, Mason WH, Lehman D, Harriman K, Cherry JD. Characteristics of Severe Bordetella pertussis Infection Among Infants ≤90 Days of Age Admitted to Pediatric Intensive Care Units - Southern California, September 2009-June 2011. J Pediatric Infect Dis Soc 2013; 2:1-6. [PMID: 26619437 DOI: 10.1093/jpids/pis105] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 10/04/2012] [Indexed: 11/14/2022]
Abstract
BACKGROUND Bordetella pertussis infection can cause severe illness and death among young infants. METHODS We collected demographic and clinical information from the medical records of infants who were ≤90 days of age and hospitalized for pertussis in 5 Southern California pediatric intensive care units (PICUs) from September 1, 2009 to June 30, 2011. Infants who died or were diagnosed with pulmonary hypertension were considered to have more severe pertussis. RESULTS Thirty-one infants were admitted to a participating PICU. Eight infants had more severe infections, 6 infants had pulmonary hypertension, and 4 infants died. The 8 infants with more severe infections had white blood cell counts that exceeded 30 000, heart rates that exceeded 170, and respiratory rates that exceeded 70 more rapidly after cough onset than the 23 infants with less severe illness. CONCLUSIONS Identifying higher-risk infants earlier might allow for more rapid implementation of interventions.
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Affiliation(s)
| | | | | | | | | | | | | | - James D Cherry
- Mattel Children's Hospital, University of California, Los Angeles, California
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19
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Pertussis vaccines. Vaccines (Basel) 2013. [DOI: 10.1016/b978-1-4557-0090-5.00030-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] Open
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20
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Lashkari HP, Karuppaswamy S, Khalifa K. Pertussis-related hyperleukocytosis: role of hyperhydration and exchange transfusion. Clin Pediatr (Phila) 2012; 51:987-90. [PMID: 21946251 DOI: 10.1177/0009922811410971] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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21
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Abstract
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.
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22
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Ulloa-Gutierrez R, Boza R, Carvajal-Riggioni D, Baltodano A. Pertussis: should we improve intensive care management or vaccination strategies? Expert Rev Vaccines 2011; 10:49-53. [PMID: 21162620 DOI: 10.1586/erv.10.156] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Bordetella pertussis, responsible for one of the oldest vaccine-preventable diseases in children, has resurged in North America, Europe, Latin America and many countries around the world. Despite new recommended vaccination strategies for adolescents, pregnant women and adults, mortality is still significant in developing and developed countries. For the critical care management of the infant with pertussis, strategies include conventional ventilation, high-frequency oscillatory ventilation, extracorporeal membrane oxygenation, inhaled nitric oxygen, exchange transfusion, plasmapheresis and, more recently, leukodepletion. The paper under evaluation describes the experience of UK investigators in the management of pertussis with rapid leukodepletion for infants with extreme leukocytosis. Using this strategy, a rapid fall in the number of leukocytes was observed in these patients. Their results suggest that rapid leukodepletion should be considered in severely ill infants with pertussis and severe leukocytosis.
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Affiliation(s)
- Rolando Ulloa-Gutierrez
- Servicio de Infectología Pediátrica, Hospital Nacional de Niños de Costa Rica 'Dr. Carlos Sáenz Herrera', PO Box 1654-1000, Avenida Paseo Colón, San José, Costa Rica.
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23
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Abstract
OBJECTIVE To report early blood exchange transfusion in malignant pertussis and a favorable clinical outcome. SETTING A pediatric intensive care unit in a tertiary hospital in Geneva, Switzerland. DESIGN A descriptive case report. PATIENT An 8-wk-old girl was diagnosed with malignant pertussis (extreme leukocytosis, seizures, pneumonia, and secondary severe hypoxic respiratory failure associated with pulmonary hypertension). After administration of a one-volume blood exchange transfusion, a rapid decrease in white blood cell count (from 119,000/mm(3) to 36,500/mm(3)) was observed and followed by clinical improvement and favorable outcome despite the initial presence of all described risk factors associated with a high mortality. CONCLUSION The use of exchange blood transfusion early in the course of the disease might help to prevent a fatal outcome of malignant pertussis.
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Menif K, Bouziri A, Khaldi A, Hamdi A, Belhadj S, Benjaballah N. Coqueluche et hypertension artérielle pulmonaire fatale. Arch Pediatr 2010; 17:1550-2. [PMID: 20943356 DOI: 10.1016/j.arcped.2010.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2009] [Revised: 07/01/2009] [Accepted: 08/09/2010] [Indexed: 10/19/2022]
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25
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Rowlands HE, Goldman AP, Harrington K, Karimova A, Brierley J, Cross N, Skellett S, Peters MJ. Impact of rapid leukodepletion on the outcome of severe clinical pertussis in young infants. Pediatrics 2010; 126:e816-27. [PMID: 20819895 DOI: 10.1542/peds.2009-2860] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Bordetella pertussis is a common, underrecognized, and vaccine-preventable cause of critical illness with a high mortality in infants worldwide. Patients with severe cases present with extreme leukocytosis and develop refractory hypoxemia and pulmonary hypertension that is unresponsive to maximal intensive care. This may reflect a hyperviscosity syndrome from the raised white blood cell (WBC) count. Case reports suggest improved outcomes with exchange transfusion to reduce the WBC count. Our objective was to quantify possible benefits of aggressive leukodepletion. METHODS We, as a regional PICU and extracorporeal membrane oxygenation referral center, adopted a strategy of aggressive leukodepletion in January 2005. The impact of this strategy on crude and case mix-adjusted survival of all infants who were critically ill with B pertussis were compared with control subjects from January 2001 to December 2004 and Extracorporeal Life Support Organisation registry data. RESULTS Nineteen infants (7 [37%] boys) received intensive care for B pertussis from 2001 to 2009. Admission WBC counts were equivalent in 2 time periods: 2001-2004 (mean: 52,000/μL) and 2005-2009 (mean: 75,000/μL). In 2001-2004, 5 (55%) of 9 patients survived the ICU. Between 2005 and 2009, 9 (90%) of 10 patients survived. When case-mix adjustment for age, WBC count, and extracorporeal membrane oxygenation referral were considered, the 2001-2004 predicted survival (4.4 [49%] of 9.0) was equivalent to the observed mortality (4.0 [44%] of 9.0). Between 2005 and 2009, observed mortality (1.0 [10%] of 10.0) was significantly better than predicted (4.7 [47%] of 10.0). CONCLUSIONS Leukodepletion should be considered in critically ill infants with B pertussis and leukocytosis.
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Affiliation(s)
- Helen E Rowlands
- Cardiac Critical Care Unit, Great Ormond Street Hospital for Children NHS Trust, and Critical Care Group, Portex Unit, Institute of Child Health, University College London, London, UK
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26
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Sawal M, Cohen M, Irazuzta JE, Kumar R, Kirton C, Brundler MA, Evans CA, Wilson JA, Raffeeq P, Azaz A, Rotta AT, Vora A, Vohra A, Abboud P, Mirkin LD, Cooper M, Dishop MK, Graf JM, Petros A, Klonin H. Fulminant pertussis: a multi-center study with new insights into the clinico-pathological mechanisms. Pediatr Pulmonol 2009; 44:970-80. [PMID: 19725100 DOI: 10.1002/ppul.21082] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pertussis carries a high risk of mortality in very young infants. The mechanism of refractory cardio-respiratory failure is complex and not clearly delineated. We aimed to examine the clinico-pathological features and suggest how they may be related to outcome, by multi-center review of clinical records and post-mortem findings of 10 patients with fulminant pertussis (FP). All cases were less than 8 weeks of age, and required ventilation for worsening respiratory symptoms and inotropic support for severe hemodynamic compromise. All died or underwent extra corporeal membrane oxygenation (ECMO) within 1 week. All had increased leukocyte counts (from 54 to 132 x 10(9)/L) with prominent neutrophilia in 9/10. The post-mortem demonstrated necrotizing bronchitis and bronchiolitis with extensive areas of necrosis of the alveolar epithelium. Hyaline membranes were present in those cases with viral co-infection. Pulmonary blood vessels were filled with leukocytes without well-organized thrombi. Immunodepletion of the thymus, spleen, and lymph nodes was a common feature. Other organisms were isolated as follows; 2/10 cases Para influenza type 3, 2/10 Moraxella catarrhalis, 1/10 each with respiratory syncytial virus (RSV), a coliform organism, methicillin-resistant Staphylococcus aureus (MRSA), Haemophilus influenzae, Stenotrophomonas maltophilia, methicillin-sensitive Staphylococcus aureus (MSSA), and candida tropicalis. We postulate that severe hypoxemia and intractable cardiac failure may be due to the effects of pertussis toxin, necrotizing bronchiolitis, extensive damage to the alveolar epithelium, tenacious airway secretions, and possibly leukostasis with activation of the immunological cascade, all contributing to increased pulmonary vascular resistance. Cellular apoptosis appeared to underlay much of these changes. The secondary immuno-compromise may facilitate co-infection.
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Affiliation(s)
- Mohammad Sawal
- Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
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27
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Paddock CD, Sanden GN, Cherry JD, Gal AA, Langston C, Tatti KM, Wu KH, Goldsmith CS, Greer PW, Montague JL, Eliason MT, Holman RC, Guarner J, Shieh WJ, Zaki SR. Pathology and pathogenesis of fatal Bordetella pertussis infection in infants. Clin Infect Dis 2008; 47:328-38. [PMID: 18558873 DOI: 10.1086/589753] [Citation(s) in RCA: 212] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Each year, Bordetella pertussis infection causes an estimated 294,000 deaths worldwide, primarily among young, nonvaccinated children. Approximately 90% of all deaths due to pertussis in the Unites States occur in young infants. These children often develop intractable pulmonary hypertension; however, the pathophysiologic mechanism responsible for this complication has not been well characterized, and there have been no detailed descriptions of the pathology of this disease since the 1940s. METHODS Respiratory tissue samples obtained at autopsy from 15 infants aged <or=4 months who had polymerase chain reaction- or culture-confirmed B. pertussis pneumonia were evaluated by multiple histochemical stains, immunohistochemical evaluation, and electron microscopic examination. RESULTS The pulmonary histopathologic examination of the samples revealed a descending infection dominated by necrotizing bronchiolitis, intra-alveolar hemorrhage, and fibrinous edema. All samples had marked leukocytosis, and most showed luminal aggregates of abundant leukocytes in small pulmonary arteries, veins, and lymphatics. A novel immunohistochemical stain for B. pertussis revealed abundant extracellular bordetellae in cilia of the trachea, bronchi, and bronchioles, as well as intracellular bacteria and antigens in alveolar macrophages and ciliated epithelium. CONCLUSIONS Pertussis should be suspected in any infant death associated with marked leukocytosis, bronchopneumonia, or refractory pulmonary hypertension, particularly in children aged <or=4 months. The pathologic findings identified in the respiratory tracts of these children, in addition to recognized physiologic responses of the infant lung to hypoxia, suggest that B. pertussis pneumonia triggers a cascade of events that includes acute pulmonary vasoconstriction and pertussis toxin-mediated increases in circulating leukocyte mass. These responses ultimately compromise pulmonary blood flow, exacerbate hypoxemia, and create a vicious cycle of refractory pulmonary hypertension.
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Affiliation(s)
- Christopher D Paddock
- Infectious Disease Pathology Branch, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
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Abstract
Multiple organ system extracorporeal support effectively supports brain, heart, lung, liver, kidney, coagulation, red blood cell, and immune cell function in the sickest infants and children who have multiple organ system failure. These therapies have optimum benefit if: (1) the underlying disease is reversible; (2) the therapies are performed expertly and are monitored to prevent and minimize systemic hemolysis; and (3) the therapies are provided in a goal-directed manner. These therapies represent a significant advance in pediatric critical care medicine. This article provides a framework for this multidisciplinary team approach for implementing these therapies.
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Affiliation(s)
- Joseph A Carcillo
- Pediatric Critical Care, Children's Hospital of Pittsburgh, 3705 Fifth Ave., Pittsburgh, PA 15213, USA.
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Namachivayam P, Shimizu K, Butt W. Pertussis: severe clinical presentation in pediatric intensive care and its relation to outcome. Pediatr Crit Care Med 2007; 8:207-11. [PMID: 17417115 DOI: 10.1097/01.pcc.0000265499.50592.37] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe our institutional experience in the management of infants and children with pertussis admitted during a 20-yr period (January 1985 through December 2004) and also to study the relation between method of presentation and outcome. SETTING Pediatric intensive care unit in a university-affiliated tertiary pediatric hospital in Melbourne, Australia. DESIGN/METHODS Retrospective review of medical records and radiology reports of patients with a diagnosis of pertussis identified from the pediatric intensive care unit database. RESULTS A total of 49 patients (median age, 6 wks; interquartile range, 4-8 wks) required 55 admission episodes to the pediatric intensive care unit. Main reasons for admission were apnea with or without cough paroxysms (63%), pneumonia (18%), and seizures (10%). None of the infants had completed the primary course of immunization, and 94% had not received a single dose of pertussis vaccine. Infants presenting with pneumonia presented earlier (p = .001), had longer intensive care stay (p = .007), higher white cell count (p < or = .001), lower Pao2 at admission (p = .020), and higher mortality. Six infants out of seven needing circulatory support died (including all four treated with extracorporeal membrane oxygenation), and all deaths (n = 7) occurred in infants who had pneumonia at presentation. CONCLUSION Patients with pertussis, presenting as apnea (with or without cough paroxysms), treated in the pediatric intensive care unit had 100% survival. However, pneumonia as the main reason for admission and the need for circulatory support is associated with a very poor outcome. A deeper understanding of the molecular basis of Bordetella pertussis and its relation to the human host might offer means for future therapies.
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