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.
Sawal
Mohammad
M
Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK.
Cohen
Marta
M
Irazuzta
Jose E
JE
Kumar
Ramani
R
Kirton
Christine
C
Brundler
Marie-Anne
MA
Evans
Clair Anne
CA
Wilson
John Andrew
JA
Raffeeq
Parakkal
P
Azaz
Amer
A
Rotta
Alexandre T
AT
Vora
Ajay
A
Vohra
Amit
A
Abboud
Patricia
P
Mirkin
L David
LD
Cooper
Mehrengise
M
Dishop
Megan K
MK
Graf
Jeanine M
JM
Petros
Andy
A
Klonin
Hilary
H
D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001344:Autopsy; D001774:Blood Chemical Analysis; D001886:Bordetella pertussis / Q000302:isolation & purification*; D002423:Cause of Death; D015331:Cohort Studies; D003131:Combined Modality Therapy; D016638:Critical Illness; D018450:Disease Progression; D015199:Extracorporeal Membrane Oxygenation; D005260:Female; D006801:Humans; D007150:Immunohistochemistry; D007223:Infant; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal; D008297:Male; D012121:Respiration, Artificial / Q000379:methods; D012131:Respiratory Insufficiency / Q000175:diagnosis / Q000401:mortality*; D012189:Retrospective Studies; D018570:Risk Assessment; D006113:United Kingdom; D014917:Whooping Cough / Q000401:mortality* / Q000473:pathology* / Q000628:therapy
D000900:Anti-Bacterial Agents