Coquaz-Garoudet Mathilde, Ploin Dominique, Pouyau Robin, Hoffmann Yoav, Baleine Julien-Frederic, Boeuf Benoît, Patural Hugues, Millet Anne, Labenne Marc, Vialet Renaud, Pinquier Didier, Cotillon Marie, Rambaud Jérôme, Javouhey Etienne
Service de Réanimation et Urgences Pédiatriques, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677, Bron cedex, France.
Laboratoire de Virologie et Pathologie Humaine-VirPath Team, Faculté de Médecine RTH Laennec, CNRS, UMR5308, INSERM U1111, Centre International de Recherche en Infectiologie (CIRI), École Normale Supérieure de Lyon, 7-11 rue Guillaume Paradin, 69372, Lyon cedex 08, France.
Ann Intensive Care. 2021 May 7;11(1):70. doi: 10.1186/s13613-021-00856-y.
Malignant pertussis (MP) affects young infants and is characterized by respiratory distress, perpetual tachycardia and hyperleukocytosis up to 50 G/l, leading to multiple organ failure and death in 75% of cases. Leukodepletion may improve prognosis. A therapeutic strategy based on leukodepletion and extracorporeal life support (ECLS) according to different thresholds of leucocytes has been proposed by Rowlands and colleagues. We aimed at identifying factors associated with death and assess whether the respect of the Rowlands' strategy is associated with survival.
We reviewed all MP infants hospitalized in eight French pediatric intensive care units from January 2008 to November 2013. All infants younger than 3 months of age, admitted for respiratory distress with a diagnosis of pertussis and WBC count ≥ 50 G/l were recorded. Evolution of WBC was analyzed and an optimal threshold for WBC growth was obtained using the ROC-curve method. Clinical and biological characteristics of survivors and non-survivors were compared. Therapeutic management (leukodepletion and/or ECLS) was retrospectively assessed for compliance with Rowlands' algorithm (indication and timing of specific treatments).
Twenty-three infants were included. Nine of 23 (40%) died: they presented more frequently cardiovascular failure (100% vs 36%, p = 0.003) and pulmonary hypertension (PHT; 100% vs 29%, p = 0.002) than survivors and the median [IQR] WBC growth was significantly faster among them (21.3 [9.7-28] G/l/day vs 5.9 [3.0-6.8] G/l/day, p = 0.007). WBC growth rate > 12 G/l/day and lymphocyte/neutrophil ratio < 1 were significantly associated with death (p = 0.001 and p = 0.003, respectively). Ten infants (43%) underwent leukodepletion, and seven (30%) underwent ECLS. Management following Rowlands' strategy was associated with survival (100% vs 0%; p < 0.001, relative risk of death = 0.18, 95%-CI [0.05-0.64]).
A fast leukocyte growth and leukocytosis with neutrophil predominance during acute pertussis infection were associated with death. These findings should prompt clinicians to closely monitor white blood cells in order to early identify infants at risk of fatal outcome during the course of malignant pertussis. Such an early signal in infants at high risk of death would increase feasibility of compliant care to Rowlands' strategy, with the expectation of a better survival.
恶性百日咳（MP）影响婴幼儿，其特征为呼吸窘迫、持续性心动过速以及白细胞增多症，白细胞计数高达50G/l，75%的病例会导致多器官功能衰竭和死亡。白细胞去除术可能改善预后。Rowlands及其同事提出了一种基于白细胞去除术和体外生命支持（ECLS）的治疗策略，该策略依据不同的白细胞阈值。我们旨在确定与死亡相关的因素，并评估遵循Rowlands策略是否与生存相关。
我们回顾了2008年1月至2013年11月期间在法国8个儿科重症监护病房住院的所有MP婴儿。记录所有年龄小于3个月、因呼吸窘迫入院且诊断为百日咳且白细胞计数≥50G/l的婴儿。分析白细胞的变化，并使用ROC曲线方法获得白细胞增长的最佳阈值。比较幸存者和非幸存者的临床和生物学特征。回顾性评估治疗管理（白细胞去除术和/或ECLS）是否符合Rowlands算法（特定治疗的指征和时机）。
纳入23例婴儿。23例中有9例（40%）死亡：与幸存者相比，他们更常出现心血管衰竭（100%对36%，p = 0.003）和肺动脉高压（PHT；100%对29%，p = 0.002），且其中位[IQR]白细胞增长明显更快（21.3[9.7 - 28]G/l/天对5.9[3.0 - 6.8]G/l/天，p = 0.007）。白细胞增长率>12G/l/天和淋巴细胞/中性粒细胞比值<1与死亡显著相关（分别为p = 0.001和p = 0.003）。10例婴儿（43%）接受了白细胞去除术，7例（30%）接受了ECLS。遵循Rowlands策略的治疗与生存相关（100%对0%；p < 0.001，死亡相对风险 = 0.18，95%可信区间[0.05 - 0.64]）。
急性百日咳感染期间白细胞快速增长和以中性粒细胞为主的白细胞增多症与死亡相关。这些发现应促使临床医生密切监测白细胞，以便在恶性百日咳病程中早期识别有致命结局风险的婴儿。对于有高死亡风险的婴儿，这样一个早期信号将增加遵循Rowlands策略进行合规治疗的可行性，期望能有更好的生存。
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