Early blood exchange transfusion in malignant pertussis: a case report

Risk factors and mortality in children with severe pertussis: the role of exchange transfusion in a PICU

OBJECTIVE

Although multiple risk factors have been reported for adverse outcomes in children with severe pertussis, their predictive values and the benefits of interventions such as exchange transfusion remain poorly understood. Therefore, we aimed to comprehensively evaluate the risk factors associated with mortality in children with severe pertussis and assess the potential benefits of exchange transfusion therapy.

METHODS

A retrospective analysis of 170 pertussis patients admitted to the Pediatric Intensive Care Unit (PICU) between January 2018 and June 2024 was performed.

RESULTS

Among the 170 patients, 38 (22.35%) died. The death group exhibited significantly higher white blood cell (WBC) counts (67.31 vs. 28.41 × 10^9/L, P < 0.001), neutrophils (29.95 vs. 11.61 × 10^9/L, P < 0.001), and C-reactive protein (CRP) (29 vs. 8 mg/L, P < 0.001). Additionally, sepsis (39.47% vs. 9.09%, P < 0.001), shock (63.16% vs. 6.06%, P < 0.001), ARDS (23.68% vs. 2.27%, P < 0.001), and acute kidney injury (21.05% vs. 0.76%, P < 0.001) were more prevalent in the death group. ROC analysis showed that WBC counts had a predictive value for mortality (AUC = 0.75, sensitivity = 0.78, specificity = 0.68), with an optimal cutoff of 48.58 × 10^9/L.

CONCLUSION

High WBC counts are significantly correlated with increased mortality risk in severe pertussis children, with a threshold of 48.58 × 10^9/L marking high risk. Although exchange transfusion can reduce WBC counts and improve symptoms, its benefit is limited in patients with severe secondary infections, necessitating tailored treatment strategies.

Use and Waste of Reconstituted Whole Blood Exchange Transfusions: An 11-year National Observational Study

OBJECTIVES

To identify indications for exchange transfusions, assess the use and waste of exchange transfusion products (ie, reconstituted whole blood exchange transfusions), and determine nationwide distribution and prevalence of these transfusions in the Netherlands.

STUDY DESIGN

All 9 neonatal intensive care units and 15 non-neonatal intensive care unit hospitals participated in this retrospective, observational, cohort study. We retrieved data on the indications for and use of all exchange transfusion products ordered by participating centers over an 11-year period.

RESULTS

A total of 574 patients for whom 1265 products were ordered were included for analyses. Severe ABO (32.6%) and non-ABO (25.2%) immune hemolysis and subsequent hyperbilirubinemia were the most frequent indications. Rare indications were severe leukocytosis in Bordetella pertussis (2.1%) and severe anemia (1.5%). Approximately one-half of all ordered products remained unused. In 278 of 574 neonates (48.4%), ≥1 products were not used, of which 229 (82.7%) were due to the resolving of severe hyperbilirubinemia with further intensification of phototherapy. The overall prevalence of neonates who received an exchange transfusion was 14.6:100 000 liveborn neonates.

CONCLUSIONS

A considerable proportion of products remained unused, and annually a limited number of patients are treated with an exchange transfusion in the Netherlands, highlighting the rarity of the procedure in the Netherlands.

Risk Factors of Exchange Blood Transfusion in Infants With Severe Pertussis

Exchange blood transfusion (ET) reportedly improves the outcomes of the patients with severe pertussis accompanied with deadly complications continued to worsen despite intensive therapeutic measures. This study assessed the medical records of 12 patients with severe pertussis requiring ET therapy who were admitted to our medical center. Of the 12 patients requiring ET therapy, 8 survived and 4 died. The independent risk factors for requiring ET therapy in infants with severe pertussis were T ≥ 38.5°C (odds ratio [OR], 11.697; 95% confidence interval [CI], 1.325-262.184; P = .046), C-reactive protein (CRP) >30 mg/L (OR, 62.393; 95% CI, 6.264-2381.773; P = .004), and WBC > 40.0 × 109/L (OR, 68.509; 95% CI, 8.118-1829.695; P = .001). ET therapy worked effectively for our severe pertussis cases. When the severe pertussis patients with T ≥ 38.5°C, CRP >30 mg/L, and WBC > 40.0 × 109/L, ET therapy might be taken into consideration.

Severe Pertussis Infection With Hyperleukocytosis in a 10-Month-Old Unvaccinated Amish Female: A Case Report

Bordetellapertussis (B. pertussis) commonly infects individuals of all ages. However, pertussis, the disease caused by B. pertussis infection, is most severe in young infants. Severe pertussis, defined by the presence of refractory hypoxemia, pneumonia, cardiogenic shock, and hyperleukocytosis, is associated with significant morbidity and mortality. Both hyperleukocytosis and pulmonary hypertension have been found to be predictive of mortality in young infants. Leukoreductive strategies such as leukapheresis and exchange transfusion have been employed to treat these complications. Pulmonary hypertension is thought to be a result of aggregation of white blood cells in pulmonary vasculature; however, studies have suggested that the mechanism of pulmonary hypertension is multifactorial. We report a case of a 10-month-old unvaccinated Amish female with pertussis complicated by an initial hyperleukocytosis of 204,900 10³/uL successfully treated with leukapheresis in our pediatric intensive care unit. This infant never showed signs of pulmonary hypertension, which is often associated with hyperleukocytosis in severe or fatal cases of pertussis in infants and neonates. To our knowledge, this is the most significant degree of hyperleukocytosis reported in pertussis. The findings in this case support the clinical utility of leukoreductive therapy in severe pertussis and provide some evidence that the mechanism of pulmonary hypertension in these patients is multifactorial.

[Complications of pertussis]

Patients with pertussis can have a variety of complications, including pneumonia and subconjunctival hemorrhage. Severe complications, such as pulmonary hypertension and encephalopathy, can be life-threatening. Younger children with pertussis may lack the characteristic clinical manifestations of pertussis, and therefore, a deeper understanding of the complications of pertussis may help to improve the diagnosis, treatment, and prognosis of pertussis. However, there is still no standard for the diagnosis and treatment of pertussis complications, and there are great differences in diagnostic name, basis, and data used in different reports. This article reviews the complications of pertussis which have been reported so far, such as pulmonary complications (pneumonia, pulmonary hypertension, pneumothorax, and mediastinal or subcutaneous emphysema), fractures, hernias, circulatory system complications, nervous system complications (convulsion, encephalopathy, hemorrhage, and hematoma), urinary system complications, and secondary infections, so as to provide a reference for the clinical diagnosis and treatment of pertussis complications, scientific research on pertussis complications, and the promotion of standardized diagnosis and treatment of pertussis complications.

Fatal malignant pertussis with hyperleukocytosis in a Chinese infant: A case report and literature review

RATIONALE

Pertussis has re-emerged on a global scale and is an ongoing public health problem, even in countries with high rates of vaccination. Hyperleukocytosis [white blood cell (WBC) count >100 × 10/L] is a rare complication that strongly predicts mortality in cases of severe pertussis.

PATIENT CONCERNS

We report a case of severe pertussis in an infant who initially presented with persistent cyanotic cough, tachypnea, and grunting. The infant's condition deteriorated rapidly, and she was transferred to the pediatric intensive care unit (PICU) during her third hour of hospitalization. On the third hospital day, her WBC count had increased to 101.85 × 10/L with a lymphocyte count of 36.76 × 10/L, and her hemoglobin level had fallen to 6.9 g/dL. Bone marrow examination found no evidence of tumor cells. Her initial echocardiogram showed no abnormal findings; however, a subsequent echocardiogram 10 days later revealed pulmonary hypertension.

DIAGNOSES

The patient was diagnosed with severe pneumonia, which was confirmed to be pertussis based on a persistent cough in the infant's mother and the polymerase chain reaction and culture of the infant's nasopharyngeal secretions being positive for Bordetella pertussis.

INTERVENTIONS

The infant was treated with supportive care, early macrolide antibiotics, and broad-spectrum antibiotics before being transferred to the PICU for further management, including continuous venovenous hemodiafiltration.

OUTCOMES

Unfortunately, the infant died as a result of pulmonary hypertension and multiorgan failure.

LESSONS

Exchange transfusion should be considered in all infants who present with severe pertussis with hyperleukocytosis. This guideline is supported by the findings of a comprehensive literature review, which is included in this article, as well as newly published criteria for exchange transfusion therapy. Finally, we hope that adults in China will be vaccinated against B. pertussis in order to prevent the infection of infants within their households.

Extracorporeal Membrane Oxygenation for Pertussis: Predictors of Outcome Including Pulmonary Hypertension and Leukodepletion

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.

The use of cytapheresis in the treatment of infectious diseases

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.

Leukemoid Reaction in Infant Pertussis: Is There a Place for Hydroxyurea? A Case Report

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.

Identifying Children at Risk of Malignant Bordetella pertussis Infection

OBJECTIVE

To identify factors associated with malignant pertussis.

DESIGN

A retrospective case notes review from January 2003 to August 2013. Area under the receiver-operator characteristic curve was used to determine how well vital sign and white cell characteristics within 48 hours of hospital presentation identified children with malignant pertussis.

SETTING

The national children's hospital in Auckland, New Zealand.

PATIENTS

One hundred fifty-two children with pertussis.

MEASUREMENTS AND MAIN RESULTS

There were 152 children with confirmed pertussis identified, including 11 children with malignant pertussis. The area under the receiver-operator characteristic curve was 0.88 (95% CI, 0.78-0.97) for maximum heart rate. The optimal cut-point was 180 beats/min, which predicted malignant pertussis with a sensitivity of 73% and a specificity of 91%. The area under the receiver-operator characteristic curve was 0.92 (95% CI, 0.81-1.0) for absolute neutrophil count, 0.85 (95% CI, 0.71-0.99) for total WBC count, 0.80 (95% CI, 0.63-0.96) for neutrophil-to-lymphocyte ratio, and 0.77 (95% CI, 0.58-0.92) for absolute lymphocyte count. All children with malignant pertussis had one or more of heart rate greater than 180 beats/min, total WBC count greater than 25 × 10/L, and neutrophil-to-lymphocyte ratio greater than 1.0 with an area under the receiver-operator characteristic curve of 0.96 (95% CI, 0.91-1.0) for a multivariate model that included these three variables.

CONCLUSIONS

Clinical predictors of malignant pertussis are identifiable within 48 hours of hospital presentation. Early recognition of children at risk of malignant pertussis may facilitate early referral to a PICU for advanced life support and selection for trials of investigational therapies.

Pertussis leukocytosis: mechanisms, clinical relevance and treatment

The significant and sometimes dramatic rise in the number of circulating white blood cells (leukocytosis) in infants suffering from pertussis (whooping cough) has been recognized for over a century. Although pertussis is a disease that afflicts people of all ages, it can be particularly severe in young infants, and these are the individuals in whom leukocytosis is most pronounced. Very high levels of leukocytosis are associated with poor outcome in infants hospitalized with pertussis and modern treatments are often aimed at reducing the number of leukocytes. Pertussis leukocytosis is caused by pertussis toxin, a soluble protein toxin released by Bordetella pertussis during infection, but the exact mechanisms by which this occurs are still unclear. In this minireview, I discuss the history of clinical and experimental findings on pertussis leukocytosis, possible contributing mechanisms causing this condition and treatments aimed at reducing leukocytosis in hospitalized infants. Since recent studies have detailed significant associations between specific levels of pertussis leukocytosis and fatal outcome, this is a timely review that may stimulate new thinking on how to understand and combat this problem.

Pertussis: Microbiology, Disease, Treatment, and Prevention

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.

Protecting Newborns Against Pertussis: Treatment and Prevention Strategies

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.

Pertussis in the newborn: certainties and uncertainties in 2014

Bordetella pertussis infection remains a serious potential health risk to infants, specially in those too young to be vaccinated. Over the recent years, numerous sources highlighted a widespread resurgence, making it, again, a challenging disease. Globally, pertussis is ranked among the 10 leading causes of childhood mortality. This review summarizes the most recent literature and will address the most important aspects that pediatricians and neonatologists must be familiar with, when treating a newborńs pertussis infection.

[Malignant pertussis and exchange transfusion]

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.

Role of therapeutic apheresis in infectious and inflammatory diseases: Current knowledge and unanswered questions

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.

Severe pertussis and hyperleukocytosis: is it time to change for exchange?

BACKGROUND

Pertussis is an important cause of infant death worldwide and continues to be a public health concern even in countries with high vaccination coverage. Severe (critical) pertussis with hyperleukocytosis is a severe form of the disease with up to 80% mortality rate. Attempts have been reported to reduce the white blood cell burden by exchange transfusion (ET) with conflicting conclusions.

CASE REPORT

We report a case of critical pertussis in a neonate who was treated with ET, in view of a comprehensive literature review.

RESULTS

The patient was discharged without any sequelae.

CONCLUSION

ET should be considered in all infants suffering from critical pertussis and hyperleukocytosis, even in secondary care community hospitals.

Exchange blood transfusion in the management of severe pertussis in young infants

We analyzed data from 10 young infants who received exchange blood transfusions for management of severe pertussis. Our data are insufficient to address efficacy of the procedure, but our data, as well as previous reports in the literature, indicate that if the procedure is to be successful, it should be done before organ failure has occurred and immediately if shock/hypotension occur.

Characteristics of Severe Bordetella pertussis Infection Among Infants ≤90 Days of Age Admitted to Pediatric Intensive Care Units - Southern California, September 2009-June 2011

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.

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.