Circulating thrombopoietin levels in neonates with infection.

Thrombocytopenia is a commonly encountered hematologic complication in neonates with sepsis. Thrombopoietin (TPO) is the principal physiologic regulator of megakariocytopoiesis and platelet production. This study was carried out to determine whether variations in circulating TPO levels would occur in infected neonates and/or if they would correlate with platelet counts. In a prospective study of 36 sick neonates (gestational age 24-42 wk) admitted to a regional Neonatal Intensive Care Unit (NICU), blood was collected for TPO measurements and platelet counts on admission to the NICU, if infection was inferred, and at recovery before discharge. An additional group of 15 apparently healthy neonates was also studied (median postnatal age at the time of blood sampling for TPO assessment: 4 d, range 1-10) as control. TPO was measured on plasma samples using a commercially available enzyme-immunosorbent assay (ELISA). On admission, the majority (21/36) of the sick neonates had non-infectious diseases, 2 had early onset sepsis, and 13 had infection (defined as the presence of clinical signs of sepsis, abnormal leukocyte counts or C-reactive protein values, and positive results on local cultures, but negative blood culture results). During the hospital stay, 5 neonates developed sepsis (positive blood culture) and 6 had infection (as previously defined) or necrotizing enterocolitis (NEC). The median TPO level (1704 pg/ml, range 51-3912) was higher during sepsis (either early or late) than during infection (included NEC) (198 pg/ml, range 21-2504), or non-infectious disease (659 pg/ml, range 0-2533), while platelet counts (median value 37,000 cells/microl, range 15,000-486,000) were lower than during either infection (included NEC) (median value 238,000 cells/microl, range 49,000-655,000) or non-infectious disease (median value 110,000 cells/microl, range 45,000-549,000). When infants had recovered from these illnesses, TPO concentrations markedly dropped (median value 59 pg/ml, range 0-825). These values were similar to those found in the control neonates (median TPO level 85 pg/ml, range 43-620). In infected neonates (sepsis plus infection), TPO levels inversely correlated with platelet counts (r = -0.634, p = 0.001) as did those of infants with non-infectious disease (r = -0.574, p = 0.006), while there was no significant correlation between TPO levels and platelet counts in the samples obtained after recovery or in the control infants. We conclude that infected neonates have high circulating TPO levels in the face of low platelet counts. Whether larger TPO concentrations following exogenous administration of recombinant TPO would restore the number of circulating platelets warrants further investigation.

[Characteristics of airway colonization in mechanically ventilated newborn infants]. / Le caratteristiche della colonizzazione delle vie aeree nel neonato ventilato meccanicamente.

This study was designed to define the pattern of airway colonization in mechanically ventilated neonates and to assess whether this is associated with clinical signs of infection and/or local or systemic inflammation. One hundred and fifty-seven bronchoalveolar lavages (BAL) were obtained from 40 intubated neonates for microbiologic and cytologic evaluation of the distal airway. Concomitantly with each BAL, clinical data and laboratory tests were recorded. Ninety-seven BAL were negative, whilst 56 (37%) yielded the growth of gram-positive bacteria (84%), gram-negative bacteria (6%), fungi (5%), or P. carinii (5%). Airway colonization occurred in 9 (22%) neonates within the first 72 hours of life and in 31 (78%) during the following days. S. aureus was the most commonly isolated organism (70%). Clinical signs of pulmonary infection were present in all cases of vertical colonization and in 35 (66%) of nosocomial transmission. Blood and BAL white cell counts were higher coincidentally with airway colonization (p = 0.13 and p = 0.57, respectively). Antibiotic treatment was changed on the basis of BAL culture results. Follow-up cultures of the BAL were obtained in 13 neonates in whom antibiotics were changed. Negative cultures were found in 8 of these neonates, and 50% of these cases showed clinical improvement. Further work is needed to assess the cost-benefit ratio of prophylactic antibiotic administration in intubated neonates and the possible advantage(s) of treating microorganisms colonizing the airway of these subjects.

[Purpura fulminans in the newborn. Report of two cases successfully treated with heparin and antithrombin III]. / La purpura fulminans nel neonato. Descrizione di due casi trattati efficacemente con eparina ed antitrombina III.

Purpura fulminans is a rare form of disseminated intravascular coagulation characterized by rapidly progressive purpuric lesions, hypotension and, in some cases, fever. In neonates, purpura fulminans usually develops following deficiency of anticoagulant protein C or S, although acquired forms have been described. The management of disseminated intravascular coagulation is still controversial, with some studies finding a positive effect of anticoagulants and others showing no effect or even a detrimental one. Therefore, at present, management is limited to the treatment of underlying disease and replacement of clotting factors. Personal experience is reported on the efficacy of heparin in combination with antithrombin III in the treatment of purpura fulminans in two preterm neonates who did not have inherited deficiency of protein C or S and developed the disease possibly following prolonged labor (36 hours) in the first case, and maternal neoplasia, in the second. Both neonates presented with widespread cyanotic areas rapidly evolving in purpuric lesions and hemorrhagic bullae. Laboratory tests (prolonged prothrombin and partial thromboplastin time, fibrinogen and antithrombin III concentrations below normal ranges, d-dimer highly positive) were consistent with disseminated intravascular coagulation. In both cases anticoagulant treatment with heparin (50 UI/kg in bolus followed by 15 UI/kg/h) and antithrombin III was associated with resolution of disseminated intravascular coagulation and prompt amelioration of the purpuric lesions, without apparent side effects.