Current Trends Acute Pulmonary Hemorrhage Among Infants -- Chicago, April 1992-November 1994

A cluster of cases of acute pulmonary hemorrhage of unknown etiology occurred among eight infants in Cleveland during January 1993-November 1994 (1). During the investigation of these cases, a similar cluster was identified in the Chicago area. From April 1992 through November 1994, seven infants with acute pulmonary hemorrhage of unknown etiology were admitted to hospitals in the Chicago area. Four of the infants were treated at the same hospital in which, during the preceding 3 years (1989-1991), one case of pulmonary hemorrhage among infants had been diagnosed. This report summarizes the preliminary results of the ongoing epidemiologic, clinical, and laboratory investigations of these cases by pediatric pulmonologists in Chicago, the Illinois Department of Public Health, the Chicago Department of Public Health, the Cook County Department of Public Health, and CDC.

A surveillance case definition for acute pulmonary hemorrhage among infants that was established by CDC and public health officials in Chicago is the occurrence in an infant aged less than 1 year of hemoptysis and/or epistaxis or blood obtained from endotracheal tube following atraumatic intubation, not attributed to cardiac or vascular malformations, infectious processes, or known trauma.

The two infants with the most recently diagnosed cases had been admitted to separate hospitals in October and November 1994. A review of medical records identified two additional infants hospitalized in 1992 (in April and December) and three in 1993 (in March, May, and September). At the time of admission, all seven infants were afebrile but had anemia and histories consistent with either hemoptysis (four infants), epistaxis (one), or blood from the endotracheal tube (two). In addition, acute onset of severe respiratory distress was diagnosed in all seven at the time of admission.

Six infants were black and four were male. At the time of hospitalization, the infants were aged 3 weeks-8 months (mean: 12.3 weeks). All infants were healthy previously. One infant, a twin, had been delivered at 34 weeks. Six had been delivered at full term without complications. Six infants had been fed cow's-milk-based formulas, and one had been breastfed. The residences of the infants were dispersed in an approximately 40-square-mile area.

Because of the severity of respiratory distress, all seven infants were admitted to pediatric intensive-care units and were given respiratory support by mechanical ventilation. Duration of mechanical ventilation ranged from 4 to 12 days (mean: 8 days). On admission, mean hematocrit was 26.2% (range: 17.0%-30.5% {normal: 36.0%-47.0%}), and mean hemoglobin was 7.9 mg/dL (range: 5.0 mg/dL- 9.6 mg/dL {normal: 10.0-15.0 mg/dL}). Red blood cell morphology (anisocytosis and 1+ schistocytosis) suggested mild hemolysis. For all seven infants, platelet counts were normal, and findings were within normal limits for prothrombin time and partial thromboplastin time. White blood cell counts ranged from 7.0 cells/mm superscript 3 to 26.1 cells/mm superscript 3 (mean=14.3 cells/mm superscript 3). All seven infants received blood transfusions for anemia.

Chest radiographs within 24 hours of admission indicated bilateral alveolar infiltrates in all seven infants. Bronchoscopy was performed for all seven infants to identify the source of bleeding, but no source was detected. Gastrointestinal evaluations (i.e., endoscopies and abdominal computerized axial tomography scans) performed for four of the infants also did not detect a source of bleeding. Evaluations of two of the infants for allergies to cow's milk protein through quantification of milk precipitins were negative.

Cultures of blood and urine specimens were negative for bacterial, mycotic, and viral pathogens. Cultures of tracheal aspirates were positive in one infant and yielded Serratia marcessens and Staphylococcus aureus. Twelve days after admission, respiratory syncytial virus was isolated from tracheal aspirates from one infant, but she was discharged with a diagnosis of idiopathic pulmonary hemosiderosis.

After receiving antibiotics and other supportive care, all seven infants fully recovered and were discharged. One infant died 3 weeks after discharge; lung biopsy and immunologic, gastrointestinal, and infectious disease evaluations of this infant were negative. Autopsy results were unremarkable, except for the lung parenchyma, which was dark red, poorly aerated, and oozing blood.

Active case finding has identified two potential additional cases in the Chicago area. A case-control study is in progress to determine risk factors for acute pulmonary hemorrhage among infants. A similar case-control study was initiated in Cleveland in November 1994. Reported by: ME Wylam, MD, L Lester, MD, HV Connolly, MD, Wyler Children's Hospital; S McColley, MD, Children's Memorial Hospital; P Diaz, MD, W Addington, MD, B Paul, MD, H Guerrero, MBA, U Samala, MPH, S Whitman, PhD, G Good, MS, R Lee, S Arrowsmith, R Holcombe, S Lincoln, M Jordan-Williams, Chicago Dept of Public Health; K Scott, MD, Cook County Dept of Public Health; E Donoghue, MD, B Lifshultz, MD, Office of the Medical Examiner, County of Cook, Chicago; JR Lumpkin, MD, BJ Francis, MD, State Epidemiologist, Illinois Dept of Public Health; DO Hryhorczuk, MD, L Curtis, MS, Univ of Illinois at Chicago School of Public Health. Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; Div of Environmental Hazards and Health Effects, and Div of Environmental Health Laboratory Sciences, National Center for Environmental Health; Div of Field Epidemiology, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: The cluster of cases of acute pulmonary hemorrhage among infants in Chicago was identified as a result of active case-finding efforts during the investigation of a similar cluster identified in Cleveland during November 1994 (1). Patients in both clusters have been aged less than 1 year, predominantly black, and previously healthy. Unlike the infants in Cleveland, however, the residences of the infants in Chicago were not tightly clustered geographically in one area of the city. In addition, abundant hemosiderin-laden macrophages, indicative of continued pulmonary hemorrhage, were not identified in the bronchial aspirates of the infants in Chicago. However, for six of the infants who underwent bronchoscopy, the procedure was performed within 2 weeks of the initial presentation with pulmonary hemorrhage, and hemosiderin-laden macrophages may not yet have been present.

Of the seven cases in Chicago, six were in blacks -- a finding that may be associated with socioeconomic status or with the prevalence of other specific risks, for which race is most likely a marker. Other factors being assessed through the case-control study include infant feeding practices, child-care practices, family medical histories, occupational exposures, environmental exposures, and animal/rodent exposures. In addition, through collection of clinical data, the investigation will include assessment of potential hematologic, allergenic, and genetic etiologies.

Pulmonary hemorrhage is most commonly a complication of other conditions, such as cardiac defects, vascular malformations, neoplasms, infection, milk protein allergies, and immune complex disorders (2,3), and occurs only rarely among infants. Physicians should report possible cases through state health departments to CDC's Air Pollution and Respiratory Health Branch, Division of Environmental Hazards and Health Effects, National Center for Environmental Health; telephone (404) 488-7320; fax (404) 488-7335; Internet: rae1@cehdeh1.em.cdc.gov.

References

1. CDC. Acute pulmonary hemorrhage/hemosiderosis among infants -- Cleveland, January 1993-November 1994. MMWR 1994;43:881-3.

2. Levy J, Wilmott R. Pulmonary hemosiderosis. In: Hilman BC, ed. Pediatric respiratory disease: diagnosis and treatment. Philadelphia: WB Saunders Co., 1993:543-9.

3. Kumar SR, Rosner IK, Godwin T, Rappaport I. Pulmonary hemorrhage in a young infant. Ann Allergy 1989;62:168-211.

+------------------------------------------------------------------- --------+ |             | | Erratum: Vol. 44, No. 4 | | ======================= | | SOURCE: MMWR 44(05);97 DATE: Feb 10, 1995 | |             | | In the article "Acute Pulmonary Hemorrhage Among Infants -- | | Chicago, April 1992-November 1994," on page 67, the sentence | | beginning on the fifth line was incorrect. The sentence should | | read, "For six of the infants who underwent bronchoscopy, the | | procedure was performed within 2 weeks of the initial presentation | | with pulmonary hemorrhage." | +------------------------------------------------------------------- --------+

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