Pertussis Pneumonia, Hypoxemia, Hyperleukocytosis, and Pulmonary Hypertension: Improvement in Oxygenation After a Double Volume Exchange Transfusion

Abstract

ABSTRACT. A 3-month-old infant of 33 weeks' gestation was hospitalized with pneumonia caused by Bordetella pertussis. Respiratory insufficiency worsened, and on hospital day 3, there was severe pulmonary dysfunction (arterial oxygen pressure/fraction of inspired oxygen ratio: 120), extreme leukocytosis (white blood cell count 104 000/mm 3 ), and severe pulmonary hypertension as assessed by 2-dimensional echocardiogram. A double volume exchange transfusion was performed to reduce the leukocyte mass. Oxygenation began to improve during the exchange and continued to improve over the ensuing 31 hours (arterial oxygen pressure/fraction of inspired oxygen ratio: 280). The white blood cell count fell dramatically after the exchange, and the rate of rise was slower after exchange therapy compared with preexchange. T he constellation of bronchopneumonia, extreme leukocytosis, refractory hypoxemia, and pulmonary hypertension (PHT) is well described in severe Bordetella pertussis infection in infants. 1,2 The onset of refractory hypoxemia typically is rapid 3,4 and responds poorly to advanced ventilation maneuvers, including high-frequency oscillatory ventilation, inhaled nitric oxide, and extracorporeal life support (ECLS). 5,6 The mechanism of hypoxemia and pulmonary hypertension in this setting is undetermined; however, several lines of evidence support leukocyte thrombi as the cause. White blood cell (WBC) counts Ͼ100 000 in the setting of B pertussis pneumonia are associated with increased mortality. 7,8 A leukocyte thrombus in a pulmonary venule has been reported in a fatal case of B pertussis pneumonia. 3 Finally, respiratory distress has been described in adults and children with hyperleukocytosis secondary to leukemia. 9,10 In the last setting, respiratory distress has resolved after the application of techniques to reduce the leukocyte mass, including leukopheresis and exchange transfusion. We postulated that the application of a similar strategy to reduce leukocyte mass in the setting of B pertussis pneumonia, hypoxemia, and PHT may prevent additional thrombi formation and allow resolution of preexisting thrombi. We report the first use of a double volume exchange transfusion as a therapy for B pertussis pneumonia with PHT and hypoxemia and describe the improvements in oxygenation temporally associated with that therapy. CASE REPORTSA 3-month-old, 5-kg, white girl had been seen 3 times in the 16 days before admission for cough and rhinitis. She was prescribed albuterol and a 2-day course of prednisone when she first became ill, and nebulized albuterol was prescribed at 2 subsequent visits, all with minimal improvement. The patient was seen by her primary care physician and admitted to a local hospital with mild respiratory distress. Her physical examination was remarkable for temperature 101.1°F, heart rate 176 beats/min, respiratory rate 60 breaths/min, and oxygen saturation 96% with the fraction of inspired oxygen (Fio 2 ) 0.27. Lung examination was significant for rales in all fields with a congested, "hackin...

Hyperleukocytosis in a premature infant with intrauterine herpes simplex encephalitis

“…Emergent leukapheresis or exchange transfusion has been advocated for hyperleukocytosis accompanied by respiratory distress or cardiovascular instability. [13][14][15] Exchange transfusion is not recommended for the neonate with asymptomatic leukemoid reaction. A recent review of 1200 infants with birth weight <2500 g revealed 17 cases of leukemoid reaction with peak WBC count at 9 days of age.…”

Actualización en terapias de leucorreducción como alternativas para el tratamiento de coqueluche grave

“…La reposición se efectúa con glóbulos rojos desplamatizados, o bien con una combinación de una solución de albúmina al 4,5% y un concentrado de glóbulos rojos para alcanzar un nivel final de hematocrito de 0,40 a 0,45. 23 La citorreducción como tratamiento de la coqueluche grave se inicia en 2004, 9 y existe actualmente un algoritmo terapéutico propuesto por Rowlands y cols., 23 (Figura 2), quienes reportan, en su trabajo, una disminución en la mortalidad esperada con dicho tratamiento.…”

“…9 Reportan sobre dicho procedimiento en una paciente de 3 meses de edad con coqueluche grave, HTP observada por ecocardiograma y con ARM, con resultado satisfactorio en la reducción de la masa leucocitaria, con un valor preexanguinotransfusión de GB de 104 000 mm 3 y un recuento posterior al procedimiento de 15 200 mm 3 . Constatan una mejoría en los parámetros de oxigenación (PaO 2 /FiO 2 ) y en los signos indirectos de HTP.…”

Coqueluche grave: Estado del arte

“…La TP es un conocido factor promotor de leucocitosis periférica, y en forma indirecta refleja también la cantidad de bacterias implicadas 75,79,86 . Esto generaría el desarrollo de trombos microvasculares lo que asociado a un sistema de coagulación y fibrinolítico inmaduro, generaría un síndrome de hiperviscosidad sanguínea y trombosis de las arteriolas pulmonares 80, 81,87 . Sin embargo, otros autores postulan que tras la HTP existiría un proceso vasculítico local, más que un vasoespasmo, secundario al daño del epitelio respiratorio y progresivamente del endotelio vascular, mediado por citoquinas liberadas desde los linfocitos 27,28 .…”