Successful treatment of acute respiratory distress syndrome and severe pulmonary hypertension in a child with Bordetella pertussis infection

Fulminant pertussis: a multi-center study with new insights into the clinico-pathological mechanisms

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.

Seroprevalence of IgG antibodies to pertussis toxin in the Slovene population

BACKGROUND

The use of pertussis vaccines has reduced the morbidity and mortality of whooping cough. Immunity following the natural disease or vaccination is not life-long and reinfections causing an increase of pertussis antibodies can occur. In this study, the distribution of IgG antibodies to pertussis toxin (anti-PT IgG) among different age groups in Slovenia was determined.

METHODS

The seroprevalence of anti-PT IgG antibodies to Bordetella pertussis was investigated in 3418 persons (49.1% males). The population under study was stratified into 27 age groups. The serological results were assigned to five groups, according to their titer levels. The geometric mean titers (GMT) were calculated.

RESULTS

In 11.5% sera tested, no IgG antibodies to pertussis toxin were detected. High titers (> or =125 U/ml) were confirmed in 2.3% sera. There were no statistically significant differences between age groups in the proportion of antibody levels. Pre-school children from three to five years of age had the lowest anti-PT IgG GMTs (9.6-10.7 U/ml). Vaccinated children (aged from one to two years) and adolescents from 17-18 years of age had the highest GMTs (>20 U/ml). GMTs were not statistically significantly different between males and females.

CONCLUSIONS

The study demonstrated an early decline of anti-PT IgG after vaccination. According to the serological profile, school-age children and adolescents have the highest rate of infection. The large proportion of seropositive adults indicates that reinfection with B. pertussis is relatively common.