The tale of two cases of pertussis with Gram- positive sepsis: Streptococcus pneumoniae and Staphylococcus MRSE. Happy vs sad end: what was different? The first exchange blood tranfusion in Poland for pertussis-induced hyperleucocytosis
Author(s):
Mierzewska-Schmidt M., Baranowski A.
Institute(s):
Medical University of Warsaw, Dept of Paediatric Anesthesiology and Intensive Therapy, Warsaw, Poland
Text:
Background: Pertussis is a potentially lethal, vaccine-preventable disease. Mortality is high in infants with hyperleucocytosis (HL) and resulting pulmonary hypertension (PH). Coinfections are common but there are few published cases of pertussis and sepsis. The aim is to present 2 such cases, their treatment and possible cause of different outcome.
Cases presentation: Both infants (5weeks/3months) had family-acquired pertussis, hyperleucocytosis (HL) resulting in pulmonary hypertension (PH) and cardiac failure (CF), also very high PLT count was observed. We suspected pertussis, but because of the severity of the condition, possibly worsened by sepsis, initially they both received clarithromycine with vancomycine and cefotaxym.
In case 1: a rapid increase in WBC to 97000/µL, progressive CF and extreme PH was resistant to catecholamines and milrinone. Inhaled NO was ineffective. ECMO was not available. We thought about exchange blood transfusion (EBT) but the baby died before, after 14 hours in PICU.
In case 2: despite treatment WBC increased at day 4 to 110300/µL, with rapid clinical deterioration, high 02 demand, CF and signs of PH. Double-volume EBT ( the 1. in Poland) led to rapid improvement, WBC dropped to 31000/µL. She left PICU after 27days, she is a healthy 1,5-old girl, now.
Discussion: Pertussis is a problem due to anti-vaccination movements and low resistance in adults. All modes of treatment should be known to intensivists. HL is an independent mortality risk factor. As it causes PH repetitive ECHOs are mandatory. EBT or leukaferesis are effective in reducing WBC and improve survival. ECMO may be the option for the most severe cases. EBT can be arranged even in small hospitals. In case 2. EBT was life-saving. It is important to consider coinfection especially in clinically severe cases with very high CRP and PCT and extremely high (G"+") or low platelet count (G"-") bacteria. In such cases broad-spectrum antibiotics should be added to macrolide treatment.
Learning points:
1. Hyperleucocytosis (HL) + cough should make us think about pertussis. It causes PH and is a risk factor of mortality.
2. Effective therapies for HL exist: exchange blood transfusion and leukaferesis.
3. Macrolide monotherapy for pertussis may be risky if clinical and laboratory findings suggest bacterial coinfection including sepsis. In such cases broad spectrum antibiotics should be added.
4. Vaccination promotion for babies, pregnant women and families is urgently needed.
Ethical Research Declaration:
7. Observational case study / series involving no new treatment / procedure
Preferred Presentation Type:
Case report

The tale of two cases of pertussis with Gram- positive sepsis: Streptococcus pneumoniae and Staphylococcus MRSE. Happy vs sad end: what was different? The first exchange blood tranfusion in Poland for pertussis-induced hyperleucocytosis