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The Hematology of Bacterial Infections in Premature Infants

A. Zipursky, J. Palko, R. Milner and G. I. Akenzua


Pediatrics 1976;57;839

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
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Illinois, 60007. Copyright 1976 by the American Academy of Pediatrics. All rights reserved. Print
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The Hematology
of Bacterial
in Premature
Infants
A. Zipursky,
F.R.C.P.(C)
the

From

Departments

Hamilton,

ABSTRACT.

A series

of

premature

M.D., F.R.C.P.(C),

ontario,

infants

of

Pediatrics

Qualitative

toxic

was

studied

changes

the sepsis-proven
provided
valuable
infections.
Thrombocytopenia

occurred

proven
group
or destniction
In

such

and seemed
of platelets

cases,

resulted

it was

from

platelets

a direct

and/or

NEUTROPHILS,

neutrophils

(DOhle

bodies,

frequently

in

the

sepsis-

to result from increased


utilization
rather
than failure
of production.

evidence

and

minimal

in

of

intravascular

concluded
effect

of

endothelium.
NEONATAL

coagulation

was

that thrombocytopenia
had
the bacteria
or its products
on
Pediatrics,
57:839-853,
1976,

SEPSIS,

and

Clinical

THROMBOCYTOPENIA.

the

Forty-nine
Regional

McMaster

cases

the
We

have

reported

infants

in

previously
which

we

and

and G. I. Akenzua,

Biostatistics,

McMaster

M.B.,

University,

our

studies

demonstrated

of
the

MATERIAL

premature
Neonatal

AND

METHODS

infants
were
studied
at
Intensive
Care
Unit,

University

Medical

Centre.

All

cases

had been referred


to the unit because
of extreme
prematurity,
need
for ventilatory
assistance,
or
other
high-risk
situations.
All
infants
included
in
this
study
were
suspected
of having
Sepsis
and,
accordingly,
studies
were undertaken
for evidence
of infection.
The clinical
course
and laboratory
studies
were
reviewed
independently
by one of us (G.I.A.)
and
the hematological
studies
by another
(J.P.).
On the basis of the clinical
review,
the cases
were divided
into three
groups:
(1) Infants
with
confirmed
infection
(sepsisproven)
(1 to 15): A culture
of blood,
cerebrospinal

hill-term

Epidemiology

CLINICAL
Subjects

for

and vacuolization)
were more frequent
in
group
and, together
with the band count,
techniques
for the diagnosis
of bacterial

granulation,

J. Palko, R.T., R. Mimer, M.I.S.,

Canada

the presence
of bacterial
infection.
On the basis of clinical
evidence
and bacteriological
studies,
they were divided
into
three
groups
in which
sepsis
was considered
to be proven,
possible,
or unlikely.
Band neutrophil
counts
were elevated
niost frequently
in the sepsis-proven
group
and the elevation occurred
usually
within
24 hours
of onset
of signs of
disease.

Infections

fluid,

or peritoneal

fluid

was

positive

in 12

for bacteria.
In one case, lung aspirate
source
of the bacteria.
In two cases,

abscesses

and

bacterial

July

29;

otitis

media

were

was
lung
found

postmortem.

importance

of nonsegmented
(band)
neutrophil
diagnosis
of infections.
In the present
study,
we have
examined
the
pattern
of hematological
changes
associated
with
counts

in

sepsis

in

of life.

the

premature

We

believe

infants

that

during

these

for earlier,
and
rial infections

more accurate,
and for greater

the

processes

pathologic

the

observations

involved.

first

month

provide

diagnosis
of bacteunderstanding
of

(Received
November

3,

ADDRESS
rics,
West,

FOR

McMaster
Hamilton,

revision

accepted

for

publication

1975.)

REPRINTS:
University
Ontario

(AZ.)

Department

Medical

Centre,

L8S4J9,

Canada.

1200

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Vol. 57
No. 6 27,
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1976

of PediatMain

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839

TABLE
CLINIcAL

FEATURES

OF

INFANTS

\VITH

CoNFIiuIEI

INFECTION

(SEPSI5-PIIoVEN)

.s7eitrophils
(per
Baiul
Ge.sta(wk)

Birthweight
(gui)

Age at
Onset
(days)

tiOH

,-

iiiiii)

Peak

Signs

Culture

Site

Outcome

Organism

Peak

(((1

S(g?lun

-,

(t1

Peak

Day

Peak

Dat,

36

2,1(X)

Shock

Blood

11. influenzae

Died day 0

-,

29

1,190

Apnea

CSF

E. coil

Alive

8,200

11

15,600

11

:1

34

1,39()

Vomiting

Peritoneum

K. aerogenes

Alive

6,100

11

13,300

11

27

1,090

Apnea

Blood

K. aerogenes

Alive

6,200

15,200

26

1,19()

Apnea

Otitis
media,
lung al)scess

18,600

28

1 ,320

Vomiting

Peritoneuin

F.

1,480

18

Apnea

Blood

S.

E.

100

Died

day

15

2,600

coil

Died

day

:3,500

epi(lerlni(lis

Alive

7,100

19

coli

Alive

3,600

weichii

Died

4,100

5,600

18,400

700

6,2(X)

2,2(X)

7,3(X)

(postmortem)

35

2,113

Fever

CSF,

30

1,640

Apnea

Blood

C.

lOt

34

1,990

Apnea,
jaundice

Blood

F. coil

Alive

31

1,370

Respiratory

Blood

E.

coli

Alive

P.

morganii

Died

--

-ii-

blood

day

7,200
12,900

19

18,200

4,300

distress

12

28

1,000

Respiratory
distress

Lung

13

35

2,680

Respiratory
distress

Blood

14

24

682

Apnea

Middle

aspirate

ear

Streptococcus

(B)

Alive

Streptococcus

(B)

Died

day

day

2,500

14,700

5,2(X)

28,3(X)

aspirate,
lung

abscess

(postmortem)

15

31

2,030

See

Figure

4.

tSee

Figure

5.

(2)

Infants

with

suggestive

(sepsis-possible)

clinical
tion

(16

course
and

skin

aspirate2)

I)lOod

(3)

was

sepsis

CSF

with

no

(32

was

clinical

the

and

Infants

to

laboratory

cases,

of bacterial

infec-

urine

X-ray,
in

the

diagnosis.

were
of

these

there

was

evidence

no

to

17,5(X)

which
was
not
significantly
2 or 3 (1,467
563
gm and

603 gm respectively).
All infants
in group
1 received
but one of group
2 (No. 28, who

However,

day of life)

negative.

infants

either

definitive

received

in group

instances,

(sep-

although

support

200

1,865

gastric

infection

cases,

Alive

1,551
gIn (SD 533)
different
from
groups

the

chest

cultures
In

S. epidernidis

of infection
these

cells

evidence

49):

suspected,

or

In

(e.g.,
pus

supported

cultures

sis-unlikely)

31):

data
culture,

Blood

evidence

to

suggestive

laboratory

culture,

Abdominal
distension

antibiotics;
3 also

antibiotics

cloxacillin,

ten

received
used

antibiotics;
died on the

were

dicloxacillin,

all
third

out

of the

18

antibiotics.

In

all

gentamycin

plus

or penicillin.

Methods

the

The cases are summarized


in Tables
I to III.
The mean gestational
age of the infants
in group
1
(sepsis-proven)
was 30.7
weeks
(SD
3.7)
which

Most
samples
were
taken
as capillary
blood
from heel punctures,
occasionally
venous
samples
(in EDTA)
were
studied.
Standard
hematologic
techniques
were employed
for cell counting
using

did
not
(30.0

a Model
prepared

diagnosis.

The

840

differ
3.0

birthweight

significantly

and

from

groups

or

33.0 3.0 weeks


respectively).
of the infants
in group
1 was

Dacie

S Coulter
using
the

and

Lewis,

Counter.
Blood
glass
spreader,

which

resulted

smears
described

in square-ended

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HEMATOLOGY
OF BACTERIAL
INFECTIONS

were
by

TABLE
CLINIcAL

FEATURES

OF

INFANTS

WITH

II

SUGGESTIVE

EVIDENCE

OF

INFECTION

(SEPSIS-POSSIBLE)

(per

Neutrophils

,_-----------_..
Segmented

Band

Ca.sc

Gestation
(ivk)

16

34

Birth-

Age

weight

Onset

(gin)

(days)

2,210

,_-.-------.----.

at

Peak
Signs

Lethargy,

Skin

diarrhea

17

30

1,430

pus

Respiratory
in

covered
with
at birth

X-ray

distress,
18

Outcome

Remarks

pus

of

chest

Peak

cii mm)

Peak

Day

Peak

Day

Alive

1,100

7,200

Alive

6,400

27,300

pneumonia

larynx

907

Lethargy

1,990

Lethargy

Alive

Urine

culture:
coil (100,000
colonies/mI)

Alive

500

5,700

1,900

12

11,700

12

19

33

20

27

808

Apnea

Alive

800

14,300

21

35

1,616

Respiratory

Alive

400

3,100

Alive

200

5,600

41,200

E.

distress
22

32

2,035

Respiratory

distress
23

29

1,160

Covered
PUS

24

34

25

26

26

34

with

Alive

12,200

I)irth

at

Lethargy

CSF: pleocytosis,
no culture

Alive

300

5,200

760

Lethargy

Neutrophils
gastric
(2)

Alive

1,800

12

10,500

12

2,041

15

Lethargy

X-ray

2,170

of

in
aspirate

2,100

Alive

100

15

Alive

700

11,100

13,300

chest

20

pneumonia

27

26

765

Jaundice

Pits

in

trachea

( Pseudomonas)
28

1,535

31

Hydronephrosis

Died

day 3

3,500

( postmortem)
29

27

21

1,100

Apnea

CSF:

pleocytosis,

culture

30

26

850

Respiratory
distress

31

31

2,100

Jaundice

Died
Netitrophils

gastric
(2)

smears

were

in which

excellent

cell

over

distribution

a large

area.

stained
ulocyte

with
May
Grunwald-Giemsa
counts
were
done
using

cresyl

blue

Platelet

or

counts

new

were

contrast
microscopy.
Coagulation
studies
techniques
developed
described
elsewhere.

The
ate

and

hematological
classify

and

morphology

The

smears

were
in

stains.

under

performed
by
our
laboratory

techniques
neutrophils

blue

manually,

and

used
bands

phase
microand

to enumerhave

been

200

23

3,500

21

in

day

1,500

9,100

12,000

Alive

100

previously.

In

aspirate

described

were

stain.
Reticeither
brilliant

methylene

done

Alive

negative

that

study,

a band

was

defined
as a neutrophil
in which
the width
of the
narrowest
segment
of the nucleus
was
not less
than one third the broadest
segment.
The normal
values
for band
and
neutrophil
counts
were
derived
from
studies
of
who were
followed
serially

180
premature
during
the

first

infants
month

of life.3
Blood
smears,
stained
with
May
GrUnwaldGiemsa
stain,
were
examined
for D#{246}hlebodies,
toxic
granulation,
and vacuoles
(Fig.
1). DOhle
bodies
are aggregates
of rough
endoplasmic
retic-

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ARTICLES

841

FIG.

1. A, A band

one

large

neutrophil

DOhle

segmented

showing

body

neutrophil

Platelet
stage

size

was

x
an

area

of

no

significant

of

platelets

either

Ilucleus.

granulation.

C,

determined

with

was

blood

the

use

of an
using

where

distributed

difference

found

at
in

erythrocytes

evenly.
on

in blood
smears
or EDTA.

heparin

A hand

were
determined
platelets
studied

smear

were

B,

standardized

Diameters
on 100

the

platelets

and

the

vacuolization.

This

micrometer.
800 magnification

and

toxic

with

micrometer.

granulation

above

showing

neutrophil

ocular

normal

(arrow)

There

was

measurements

anticoagulated

by

RESULTS

The
and

normal

month
band
which

Giemsa
were

stains
assessed

stain

neutrophils

were

vacuolization
neutrophils
2+
=
25%

4 +

as
2 +

0
=

tamed
tion

ulation
ules.

842

blue

in

75%. Toxic

normal

basis
0 =
3+

or

percentage
1 + = <

of

phils

were

top).

The

51%

3 +

cells,

and

with

the

nucleus

to 75%,
and
was quantitated
1 +

4 +

25%,

slight,

of neutrophils
convery
heavy
granulagross
toxic
gran-

obscured

by

toxic

gran-

The

within

after

with

levels

hours

In
were
the

In the
frequently

were

of

nine
already

clinical

other

appearance
of
IV).
Furthermore,

clinical

clinical

the
signs

peak

of
band

(Fig.
all

24

counts
hours
infection
counts

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HEMATOLOGY
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INFECTIONS at Indonesia:AAP Sponsored on August 27, 2014

of

band
hours

(Table
24

2,

cases

signs

within

band

during

neutro-

studied,

of infection

groups,

elevated

in

13 cases

elevated

onset

two

of

group.

15 cases

reached

onset

of the

one

all

is discussed
band

of

in

hence,

as

values

1 1 out

first

normal

difference

infections,

in

the

age;

included

normal

proven

peak
48

counts

the

the

2. In

significant

were

of

elevated

infection.

in Figure
no

(band)

during

to gestational

infants

D#{246}hlebodies,

50%

granules,

premature

nonsegmented
counts

find

relative

for

granulation,

IlloSt

could

of the
none,

granulation

approximately

Gr#{252}nwald-

hundred
neutrophils
magnification.
The

quantitated

>

May

we

counts

analysis
elsewhere
.
In infants

1). Two
x 1,250

on the
involved;
to 50%,

dark
in

light

(Fig.
at

for

neutrophil

of life are shown

group,
ulum

values

segmented

IV).

were

less

after

the

(Table
in
the

TABLE
CLINICAL

FEATURES

OF

INFANTS

No

WITH

III

DEFINITIVE

EVIDEIICE

OF

INFECTION

(SEPSIS-UNLIKELY)

(per

Neutrophils

Birth-

Age

,-------------------.

at

tion

weight

Onset

Case

(tvk)

(gui)

(days)

32

34

1,931

Peak

Outcome

mm)

,---------.-

Band
Gesta-

cii

Segmented

Peak

Peak

Day

2,000

13,900

Alive

1,700

10,400

Alive

200

4,900

6,200

400

5,700

Alive

1,400

10,700

Jaundice

Alive

1,500

16

9,800

Signs

Remarks

Respiratory

No evidence

distress

sepsis

of

Died

day 4

Peak

Day

at

autopsy

33

36

1,740

Respiratory
distress

34

35

2,150

Petechiae

35

36

2,260

NDS#{176}

36

27

1,535

NDS

37

32

1,440

38

34

2,360

39

36

2,860

NDS

40

33

1,140

NDS

Alive
Alive

Jaundice

Alive

Apnea

Alive

1,000

Alive
Fetal

growth

Alive

retardation
41

32

2,030

Respiratory

distress
42

26

1,021

16

43

35

2,950

Poor weight
gain

Alive

500

5,300

44

30

1,220

Respiratory
distress

Alive

1,400

4,500

45

27

730

Respiratory
distress

3,800

4,100

Intraventricular
hemorrhage

Died

day

16

46

36

2,040

Jaundice

Alive

800

8,200

47

34

2,040

Vomiting

Alive

100

3,300

48

33

1,830

NDS

Asphyxia

Alive
1

9,500

2,300

36
NDS

No

distinct

majority

of

abnormally

(Fig.

2, top).

Shock

illness

in

but

these

throughout

In contrast

following

neutrophil
(Table
IV),

of

infants
high

of bands

signs

onset

counts
often
if at all (Fig.

infants

groups
the

to the

the

Died

the

general

were

period

not

of study

early

appearance

of sepsis,

segmented

did not
2, bottom).

condition

rise

until

later

the
rise
in neutrophil
count
in
possible
and unlikely
sepsis was less
at 24 hours
(Table
IV)
or any
time

frequent
(Fig.

2,

bottom).
infection

onset
drop

of
in

In some
cases,
was associated

neutrophil

counts

10 (Fig.
During
change
bodies,
ulation.
cases

as in case

4).
infection,

in

apparent
a dramatic
1 (Table

the neutrophils

in appearance
vacuoles,
and,
Some
of these
shown

the
with

I) and

were

case

noted

day

1
sepsis

2,900

as a possibility.

attempted
to
quantitate
the
morphological
changes
in neutrophils
using
the
classification
described
above.
We have found
that the neutrophils of adults
and normal
newborns
are usually
0 or occasionally
1+
In the sepsis-unlikely
group,
there
were
no
cases
in which
DOhle bodies
or toxic granulation
were
above
1+
prior
to the
onset
of signs
suggestive
of infection
(Fig.
5 and 7). In case 44,
the neutrophils
were
graded
as 2 + for D#{246}hle
bodies
in one
post
sample.
In a few cases,
vacuolization
was increased
(Fig. 6). However,
in
the sepsis-proven
cases,
the D#{246}hlebodies
and
vacuolization
were
more
frequent
after
the
appearance
of signs of infection
(Fig. 5 and 6); the
changes
in toxic
granulation
were
less
pronounced.
The changes
in the sepsis-possible
group

As expected,
groups
with

suggested

to

in that
one
found
D#{246}hle
less consistently,
toxic
granchanges
are typified
by the

other

two

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27, 2014
ARTICLES

843

Figures

and

4.

We

have

were

intermediate

between

the

E
E

U
C,

0
I-

U)

-J

I-

UU

LU

z
0

14

7
DAY

OF

21

28

21

28

LIFE

cv,

E
E

40
35

Cv,

0
Ix

30
Cl)

-a
I

25

0.

0
20

ID

LU

15

10

LU

I-

LU

LU
U)

14

DAY

FIG.

2. Peak

signs

in

area

represents

from

studies

band

proven

counts

Sepsis
the
of

180

(top)

(square),
range

and

peak

possible
for

premature

normals

infants

OF

neutrophil
sepsis

who

counts

(circle)

(excluding

and

the

were

LIFE

(bottom)
after the onset of clinical
unlikely
sepsis (triangle)
cases. Shaded

highest

followed

5%).

serially

These

during

values

the

were

first

obtained

month

of

life.

844

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HEMATOLOGY
INFECTIONS

C,)

E
E

CASE #7

C,)

x
C)

U)

E
E

C)

E
E

C)
0
7.5-

(I)

a.

6.5-

o.--o

7.0-

Neutrophils

o-o

.--.Bonds

U)
I-.
U

L---#{243}

Platelets

6.0-

I-

5.5-

5.0-

20-

500-

4.5-

18-

450-

4.0-

16-

400-

3.5-

14-

350-

3.0-

12-

300-

2.5-

10-

250-

2.0-

8-

200-

1.5 -

6-

150-

1.0-

4.

100-

.5-

2-

50-

0-

0-

0-

POST

PRE

C)

-a

a.

0%

ONSET
OF
SYMPTOMS

4+oD#{244}hIeBody
. Vacuolization

3+-

2+1+0

I TFT1I
12

13

14

T1ft
15

16

17

18

DAY

FIG. 3. Case 7. Birthweight


at which
time suddenly
was cultured
from the

was 1,485 gm and gestational


became
ill during
an intravenous
intravenous
fluid and from the
antibiotic

It should
possible

neutrophils

be noted

also that in the proven


and
sepsis
groups
the qualitative
changes
in
were
abnormal
in some cases studied

OF

32

20

21

22232425

LIFE

weeks.

Well

until

infusion.
Staphylococcus
blood
stream.
Recovery

18 days

of age

epidermidis
occurred

with

therapy.

prior

groups.

age

t
19

to the onset of clinically


Possibly,
this reflected
early
of infection
appearing
before
signs.

evident
laboratory
the onset

infection.
evidence
of clinical

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on August 27, 2014


ARTICLES

845

TABLE
NEUTROPHIL

BAND

AND

STUDIED

24

WITHIN

IV

COUNTS

HOURS

IN PREMATURE

OF

Table V. There
it can be seen that
seven of the 15
proven
sepsis
patients
developed
thrombocytopenia
in the first week
after
the onset
of disease
compared
to one of the 16 sepsis-possible
and one
of the 18 sepsis-unlikely
patients.
The thrombocytopenia
could
be quite
severe,
as shown
in Figure
3 and 4. All patients
with
thrombocytopenia
in the sepsis-proven
group
fell
below
70,000/cu
mm
and
five patients
below
30,000/cu
mm. The average
duration
of thrombocytopenia
was 6.6 days with
a range
of 3 to 17

INFANTS

APPEARANCE

OF

SIGNS

OF

INFECTION

No. With
increased
Sepsis

No.

Bands

Neutrophils

13
11
10

9
4
2

3
3
0

Proven
Possible
Unlikely

Statistical
Bands
Proven
Proven
Possible

No. With
increased

Analysis

vs. unlikely
vs. unlikely

<

P0
.05
(S)
.001 (HS)

>

.05

(NS)

vs. possible
vs. unlikely

>

.05

(NS)

possible

.vs.

<

days.

In cases 7 and 10 (Fig. 3 and 4), coagulation


studies
were
performed
and the following
tests
were
found
to be in the
normal
range4
for
premature
infants:
prothrombin
time,
partial

Neutrophils

Proven
Proven
Possible

vs.

<

unlikely

.05

>

thromboplastin

(S)

.05

HS

significant;

highly

significant;

NS

not signifi-

cant.

TABLE
THROMBOCYTOPENIA

IN

INFANTS

INFECTION

IN

WAS

WHOM

BACTERIAL

SUSPECTED

Platelet

No. With
Thrombo-

No.

Studied

Sepsis

op#{176}

Countst

No.
100,000

<

/cu

No.

mm

Done

Proven

15

Possible

16

46

Unlikely

18

50

Statistical
Infants

with

Proven
Proven

42

vs.

vs.

#{176}Thrombocytopenia

counts

of

<

<

unlikely

during

the

first

t During
tNS

is defined
seven

mm
days

after

(NS)

.05

>

(5)

.05

(NS)

mm

unlikely

100,000/cu

.05

>

Platelet
counts
100,000/cu
Proven
vs. possible
Proven
vs. unlikely
Possible

Analysis

vs. possible
vs. unlikely

Possible

83

thrombocytopenia

as

two

<

.001

(HS)

<

.05

(HS)

>

.05

(NS)

consecutive

(confirmed
onset

the week after onset of signs.


not significant;
S = significant;

by
of signs

HS

platelet

blood
of

smear)

infection.

highly

signifi-

cant.

Thrombocytopenia
frequently
course
of infection.
This
is
representative
cases (Fig. 3 and
have
found
thrombocytopenia
infants

846

following

the

onset

developed
in the
seen
in the
two
4). In addition,
we
in several
other

of sepsis

thrombin

clotting

time,

and

2, 7, 8, 9, and 10. In both


cases,
factor
5
(37% and 39% respectively)
and in both
serum
fibrin split products
were slightly
elevated
with values
of 20tg and 40ig/ml
respectively
(our
normal
range
is up to 16ig/ml4).
Platelet
diameters
were
assessed
in patients
with
thrombocytopenia
to determine
if increased
platelet
production
was
reflected
by
the
appearance
of increased
numbers
of megathrombocytes.
Initially,
normal
newborns
were
studied
by examination
of heparinized
samples
of capillary
blood.
It is evident,
from
Table
VI, that a
range
of platelet
diameters
was found
which
did
not appear
to differ significantly
from that of the
adult.
The
proportion
of megathrombocytes
was

05

time,

factors

(NS)

as shown

in

low

3t)

is similar

to

that

reported

by

others.3

In several
infants
with
thrombocytopenia,
platelets
were sized during
the period
of thrombocytopenia.
In all cases,
large
platelets
were
seen during
this time (Table
VII and Fig. 8). In
addition,
in all these
patients,
there
appeared
during
the period
of thrombocytopenia,
large
platelets
with
unusually
abundant
cytoplasm
as
shown
in Figure
8.
The
hematological
changes
associated
with
sepsis occurring
in cases 7 and 10 are illustrated
in
Figures 3 and 4. In these cases, one can follow the
sequence
of changes
which
occur.
In case
7,
clinical
signs of infection
appeared
suddenly
on
the 18th day of life, presumably
due to infusion
of
contaminated
intravenous
solution.
Fortunately,
a blood
count
was taken
prior to this episode
and
six hours
later.
The
acute
rise in band
count
without
elevation
of neutrophil
count
is seen. The
next
day,
neutrophilia
was
noted
along
with
distinct
changes
in neutrophil
morphology,
with
the appearance
of DOhle bodies
and an increase
in
vacuolization.
Toxic
granulation
did not increase

Downloaded OF
fromBACTERIAL
pediatrics.aappublications.org
at Indonesia:AAP Sponsored on August 27, 2014
HEMATOLOGY
INFECTIONS

CASE
C)

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suddenly

Case

10.

became

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and

had

Recovery

1,990

several

occurred

gm

and

apneic

with

gestational

episodes.

antibiotic

OF

age

Blood

36

LIFE

weeks.

culture

grew

At

3 days

Escherichia

of

age

coli.

therapy.

ARTICLES

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on August 27, 2014

847

TABLE
TABLE
PLATELET

DIAMETERS

IN

VI

Adults
Mean
SD

Newborns

No.

AND

Tha meters

,
Group

MEGATHROMBOCYTES#{176}

NEWBORNS

IN

VII

NEWBORNS

\VITH

SEPSIS

AND

THROMBOCYTOPENIA

ADULTS

Megathromhocyt(s

(IL)

(%)

.VO.Of

Oto

1.Oto

2.Oto

0.9

1.9

2.9

Group

3.0w

3.9

>

4.0

Adults
Normal
Case7

14
1.1%
1.5%

63%
15%

32%
13%

3.5%
1.8%

0.4%
0.5%

Case

Sampies

14
11
6t
9t
6t

newborns
4

Case3

11

Mean

1.0%

68%

29%

1.5%

0.5%

SD

1.5%

11%

9%

2.0%

0.5%

3.9
2.0
17
34
14

0.5 to 5.5
0 to 7
1to25
13 to 48
lltol7

3IL#{149}

#{176}Diaineter

t These

Range

Mean

represent

all

samples

studied

during

the

period

thrombocytopenia.

period
of thrombocytopenia,
megathrombocytes
were
noted
as were
the unique
type
of platelet
described
above
(Fig.
8). This
case,
therefore,
presented
most of the hematological
features
that

significantly.
The fall in platelet
count
was noted
24 hours
after onset
of signs and progressed
over
the next three
days, returning
to normal
only on
the sixth day after
onset
of sepsis.
During
this

4-

3>-

0
0

2-

LU
1
I

:0
0

1-

00

.
0

.
.

.
#{149}#{149}
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Pre

5. DOhIe

studied

848

body

(sepsis-proven,
average

index

before

SSSSSS

Pre

PROVEN

FIG.

#{149}
#{149}sm

0
000000cIxxDo

Post

Post

POSSI

and

after

onset

BLE

of signs

sepsis-possible,
sepsis-unlikely).
DOhle body intensity
(see text)

Pre

UNLIKELY

of illness

The
per 200

Post

in the

DOhle

three

body

neutrophils

groups

index

of subjects

represents

scanned.

HEMATOLOGY
BACTERIAL
INFECTIONS at Indonesia:AAP Sponsored on August 27, 2014
Downloaded fromOF
pediatrics.aappublications.org

the

of

4-

3-

0
I

I
I

-I

#{149}s=

00

II

II

I
I

>

00

6. Netitrophil
of

index

Post

or-cy

Post

index

before

(sepsis-proven,

average

and

after

sepsis-possible,

frequency

of

vacuolization

111111

Pre

POSSIBLE

studied

the

II

Pre

vacuolization

subjects

represents

II

II
I
I
I

000000000

PROVEN

Fic.

0000000

Pre

rOt,p5

III

II

III

Post

UNLIKELY

onset

of signs

of illness

sepsis-unlikely).

(see

text)

The

per

200

in

the

three

vacuolization

neutrophils

scanned.

we

have

severe

come

Case
as well,

the

to

bacterial

10 showed
very
several
additional

onset

was

of sepsis

taken

at

mated

onset

of

newborn

infant.

similar
changes
but had,
features.
Once
again,

dramatic

time.

and

The

first

in retrospect,

counts

were

normal

Thrombocytopenia
from
the
blood
of

sepsis.

It

mm

ten

30,000/cu
penia

as characteristic
in the

blood

work

change

was

seemed

to have

the
previous
day.
Approximately
ten
later,
a subsequent
count
showed
an
in bands.
At
that
time,
qualitative
in the
neutrophils
were
also
evident.

Platelet
sepsis.

was

that

which,

neutropenia

started
hours
increase
changes

recognize

infection

persisted

for

prior

was
smear)
was

documented

hours
five

to the
evident
at the

later.

onset

as

being

Thrombocyto-

days.

DISCUSSION
The
infants

patients
hospitalized

in

this
study
at a regional

of

(as estiapparent

were
premature
neonatal
inten-

sive care unit. Since we were interested


in determining
the hematological
changes
associated
with
proven
bacterial
infections,
we
carefully
reviewed
the cases using
strict
criteria
to define
such a group.
This assessment
was made
independently

of the

hematologic

studies.

In addition,

we

defined
a group
in which
sepsis
was
deemed
possible
in our opinion
and finally
a group
in
which
it was considered
unlikely.
We also examined
a normal
series of premature
infants.
In this series,
to be reported
elsewhere,3
we excluded
those with serious
disease
and were
able to define a normal
group
for study during
the
first
month
of life.
Against
this background
of
normal
values,
it can be seen that
infants
with
proven
sepsis had high band counts
after the onset
of sepsis
(Fig.
2). These
were
found
more
frequently
in this group
than in the possible
or
unlikely
groups.
Furthermore
(Tables
I and IV)
the elevation
in band count
occurred
early in this
group,
usually
within
24 hours
of onset
of signs.

ARTICLES
Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on August
27, 2014

849

4-

3I

II

20

1-

I
I

00
0

II

0
0
0

II
0

III

00000000

Pre

000000000

Post

Toxic

index
before
and after
(sepsis-proven,
sepsis-possible,
the average
degree
of granulation

represents

The
and

neutrophil
IV); however,

majority

count
itself
rose
as seen in Figure

of infants

with

proven

later
(Tables
I
2, bottom,
the
sepsis

eventually

developed
an elevation
in neutrophil
count.
The
character
and
timing
of band
and
segmented
neutrophil
response
to infection
is typified
in case
7 (Fig. 3). In this case, the infection
resulted
from
infusion

of

Accordingly,
be determined

contaminated

intravenous

the time of onset


accurately.
The

in band

counts

delayed

rise

was

evident

fluids.

of infection
could
speed
of response

as was

the

subsequent

We conclude,
therefore,
that
an elevation
of
the band
neutrophil
count
above
the
normal
range
(Figure
2, top) is a valuable
laboratory
sign
in premature
infants
in whom
sepsis is suspected.
It is, of course,
only a laboratory
test and one that
is not

perfect

infections

response

neutropenia

850

in

since,

can
band

may

as

shown

occur

with

neutrophils.

be

the

first

in

Pre

Figure

2,

no evidence

UNLIKELY

of sepsis,

as shown

(Fig. 4).
The
fact

that

sepsis

showed

speaks

for

tion

of

the

cases

band

presence

I) and

case

of

of infection

and

sepsis-unlikely

segmented

group

may

counts

in these

cases.

group
infants
eleva-

neutrophils
also

10

possible

neutrophil

for assignment
to a possible
suggest
that
many
of these
have infection.
The occasional

band

of

some

1 (Table

elevated

the

The criteria
(Table
II)
indeed
did

in case

in

represent

the

uncon-

infections.

As in full-term
infants,
total neutrophil
counts
are of limited
value
for the diagnosis
of infection
since

elevation

Thus,

in the

is

cases

found
neutrophil
or rose only later

often

and

sepsis,

inconsistent.

we

counts
in the

which
disease

remained
(Tables

also

observed

that

top,

Furthermore,

counts

were

sign

unlikely
disease.

group,
often
Neutrophilia

we

late

of proven

of a

Furthermore,

hematological

Post

onset of signs of illness


in the three
groups
of
sepsis-unlikely).
The
toxic
granulation
index
(see text) per 200 neutrophils
scanned.

firmed

in neutrophils.

severe

Post

POSSIBLE

granulation

studied

==s:rn

0L50

SISI

Pre

PROVEN

Fac. 7.
subjects

sometimes

elevated
before
in the

in

frequently

normal,
I and IV).
neutrophil

the

sepsis-

the onset
of clinical
absence
of an increase

HEMATOLOGY
OF pediatrics.aappublications.org
BACTERIAL
INFECTIONS
Downloaded from
at Indonesia:AAP Sponsored on August 27, 2014

in band
count
may
there
is no evidence
result

of

stress

or

must
conclude,
is not a reliable

occur
in
of infection,
other

nonspecific

that

therefore,

or

patients
in
presumably

sensitive

whom
the

causes.

One

neutrophilia
test

of

itself

infections

in

newborns.
in

Cases
7 and
association

change

in

10 also

the

as

Toxic

changes

has

unusual

and

infection
and
toxic

seems
of

with

been

to

are

represent

the

normal

described

they

of infection.
D#{246}hlebodies

are

smear
of normal
of blood
smears

with

not

the

increased
granules

found

DOhle

bodies.

that

D#{246}hlebodies

in

own

indicate

2%

by us in the

of

blood

in a review
women,
found

It is of interest

the

but

leukopoiesis

that

most
pregnant
women
to 10% of neutrophils.

that

of

number
of these

production

stress

adults.
Abernathy,
of 500
normal

he found
studies

the

during

found

elsewhere,

represent

neutrophils

the
and
of

along
with
granulation.

It is unlikely
that
the actual
increases.
The
significance

presumably

study

to

that,

significant

vacuolization
are
aggregates

reticulum

intensity

neutrophils.
of granules

is

neutrophils

a response
vacuolization

granulation

staining

clearly

there

D#{246}hle bodies,
D#{246}hle bodies

endoplasmic

usually
neutrophil

none

sepsis,

circulating

appearance
of
toxic
granules.
rough

demonstrated

with

neutrophils

in his
had
Our

of

FIG. 8. Platelets
platelets.
B,
platelet
with

in the blood of premature


infants.
Megathrombocytes.
C, Unusual
abundant
cytoplasm
seen
during

period

A,

Normal

appearing

recovery

of infection.

ARTICLES
Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on August 27, 2014

851

normal

infants

bodies.

DOhle

the

proven

nuniber

occasionally
bodies

sepsis
rose

may

were

group

after

group

granulation
groups.

In

suggestion

that

frequently

after
higher

Similarly,

after
the

changes

were

DOhle

29%,

and

the
were

and

seen
than

possible

more

before.
were
seen

groups

studied

the

bacteremia.
amounts
and

of the

of

that

group,

of toxic

granula-

vacuolization

patients

in

studied

in
toxic

feature.
iably

her

study

of

granulation

as

present

always

during

sepsis

newborn
8, suggest

increased

Zieve

et al.

between
the
and bacterial

presence
infections.

of

are

consistent

although

we

vacuolated

relationship

vacuolated
They
found

neutrophils
that
in

neutrophils,
found
that
from
1% to

1 19 had
the
vacuo50%
of the

longer.

there

with
often

relate

to the

Also,

was

as

those

the

use

infection.

these

However,
they

toxic

between

particularly

in

where

seven

15 infants

HEMATOLOGY

and

cytopenia

the

that

associated

the

in

with

total

on

frequently
were

OF BACTERIAL

found

of
there

produc-

megathrombocytes
increased
platelet

recently

in our

in

sepsis.

the

cases

by

these

during

diameters.

platelets

periods

During

bone

produc(mega-

of increased

the

period

megathrombocytes

all

patients

that

platelet

patients.

poiesis
from
megakaryocyte
net-Gajdos

the

The
qualitative
numbers,

studied

not

clear.

coagulation

VII),

was increased

estimation

of

thrombo-

assessment
of marrow
as performed
by Bondifficult
and of ques-

infections

is

of
were

(Table

production

group

intravascular

numbers

platelet

large

their

scanning

platelet

that

production.
in

by

estimating

appear

from

base

of decreased

estimated

observed

concluded

resulted

They

finding

We

a series

thrombo-

They

had

as assessed

been

suggesting

reported

developed

in this
to be

In

megathrombo-

et a!. is very
tionable
value in our view. This may
for the difference
in our conclusions
Bonnet-Gajdos
et a!.
The
cause
of thrombocytopenia

of

band

of platelet

development
that
time

production.

aspirates.

found

laboratory

sepsis-proven

size

production.

of

who
with

platelet

conclusions

platelet

indices

increased
They

that platelet

thrombocytopenia

the

precludes

absolute

infection.
was seen

et
infants

newborn

thrombocytes)

qualitative

additional

series,

of the

of five

the

frequently
in
The
overlap,
clinical
onset

the

numbers

thrombocytopenia,

that

of
since
(Fig.
3

Bonnet-Gajdos

It has

granulation,

also

together

evidence
of bacterial
Thrombocytopenia

and

between

is great
as

provide

numbers

cause

series

took an average
3 to 17).
platelet
production

increased
since
during
periods
of

tion

for

later
tests

had

of

overlap

occurring
of

tion
appear

the

was
often
out that
this

limited

VII), suggesting

to

the

to be higher

in neutrophils
occur
more
with
infections
than
others.
between
values
prior
to

and

(Table

marrow

infected
and other
groups
and
before
and after
onset
samples.
It is our impression,
therefore,
changes
infants
however,

increased

cytes

was

for platelet

following
During

et

noted

considerable

appeared

this

The
present
interpretation
so rapidly

relatively

does
increase
thrombocytopenia.

the

that

that

thrombocytopenia
cases
and pointed

and capacity

of megakaryocytes

tended

in gram-

have
resulted
from
and/or
sequestration.

that
in these

122

of Zieve

and

and 4) that it must


platelet
destruction

failure

findings

both

infections.

shortened

Furthermore,
they
promptly
after
institu12 to 24 hours).
Our

found

neutrophils

seen
shown
are not

close

total
neutrophil
population.
felt that
they
disappeared
tion of antibiotics
(within
studies

never

Our
findings,
toxic
granules

in infection.
showed
a very

with
vacuolated
evidence
of sepsis.
They
lated
neutrophils
varied

852

important

was invar-

a change

babies.
that

patients

counts,

an

occurred

our patients,
thrombocytopenia
of 6.6 days to recover
(range,
Our findings
suggest
that

infection,

She felt that toxic granulation

in healthy
in Figure

last

neonatal

described
a series
of cases
in association
with sepsis in
He noted,
as we have (Table

gram-negative

was

may

respective-

than

Cohen
and Gardner
reported
a series
of adults
with thrombocytopenia
secondary
to gram-negative bacterial
infection.3
They
felt that platelet

reserves

described

a!.,

and

in
less

thrombocytopenia

positive

also
noted
prolonged

75%,

ly.
Xanthou,2

thrombocytopenia
in five cases

of the thrombocytopenia.
cases
would
support
that
thrombocytopenia
developed

but

neutrophils

In

The
severe,

was

Corrigan4
recently
of thrombocytopenia
children
and infants.

survival

great.

al.

bodies,
29%

was

of infection
of vacuolization

not

in

in the unlikely
in the possible
and
group,
there
is no

granulation

adult patients
with
they found abnormal
tion,

seen
bodies

thrombocytopenic.
some
instances
30,000/
cu mm

I), that

proven

et

Steigbigel

in

unusual
latter

onset
levels

in the

rise was
no DOhle

frequent
the

toxic

onset

often

of

was

and was more

proven

DOhle

more

and, in that group,


the
clinical
signs of infec-

onset

tion
(Fig.
5). No significant
possible
group
and almost
seen
in the unlikely
group.

Toxic

contain

found

Although

(DIC)

be the reason
and those of
in

bacterial

disseminated

has been

INFECTIONS

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on August 27, 2014

invoked

as a cause,

there
is much
evidence
against
it.
7 and 10, the evidence
of consumpcoagulopathy
was minimal.
Corrigan
recent-

Thus,

in cases

tive

ly published
associated

a series of cases of thrombocytopenia


with
sepsis.4
In some,
there

evidence
was

of DIG

minimal

It is very

or

nonexistent.

that

process.

damaging

cells.

adhere
circulating

on

on

8.

to have

are

9.

found

to

Endotoxin

platelets

aggregates

was

endothelial

endothelium.

effect

platelet

appears
cells

N Engl

7.

affected

and,

have

in

been

fact,

10.

found

during
endotoxemia
in experimental
animals.9
It may
be that,
in some
cases,
the primary
platelet
effect
is followed
by, or causes,
intravascular
coagulation.
Thus,
in cases 7 and 10, there
were mild, but significant,
depressions
of factor
5
levels
as well
as slight
increases
in fibrin
split
products.
Furthermore,
Corrigan
also found
some
evidence
of intravascular
coagulation
in association with the thrombocytopenia
of sepsis.4
It is possible
also
that
coagulation
may
be
initiated
directly
by activation
of Hageman
factor,
either
through
contact
with
damaged
endothelium2#{176} or directly
by endotoxin
activaMason
and Colman
have studied
a series of

12.
13.

14.

15.

16.

cases

of

found

DIG

due

to

gram-negative

factor

12

the

mechanism,

septicemia

levels

17.

significantly

re-

Whatever

thrombocytopenia

we

which

conclude

frequently

that
compli-

cates
severe
bacterial
infections
may
be associated
with no, or little,
evidence
of DIC.
In conclusion,
it can be said that in premature
infants

with

bacterial

changes

of band
topenia

and segmented
neutrophils.
frequently
develops
as
of

all

the

there

striking

recognition

in

infections

of

derable
help in the
of bacterial
infections

number

these

and

often

is

of

2.

Yeung

3.

Dacie

4.
5.

CY,

Tam

A: Gastric

R, Zipursky
diagnosis

20.

21.

22.

index

of megakaryocyte

meganumber.

Med

I, Kutti

1974.

Abernathy
MR: DOhle bodies
associated
with uncomplicated
pregnancy.
Blood 27:380,
1966.
Xanthou
M: Leukocyte
blood
picture
in ill newborn
babies.
Arch Dis Child
47:741,
1972.
Zieve PD, Haghshenass
M, Blanks M, Krevans
J: Vacuolization
of the
neutrophils.
Arch
Intern
Med
118:356,
1966.
Corrigan
JJ Jr: Thrombocytopenia:
A laboratory
sign of
septicemia
in infants
and children.
J Pediatr
85:219,
1974.
Cohen
P, Gardner
FH: Thrombocytopenia
as a laboratory sign and complication
of gram-negative
bacteremic
infections.
Arch Intern
Med 117:113,
1966.
Karpatkm
S, Garg
5K: The megathrombocyte
as an
index of platelet
production.
Br J Hematol
26:307,
1974.
Bonnet-Gajdos
M, Navarro
J, Roy C: Insufficance
tran-

et erythroblastes
an cours
chez le nourrisson.
Noiv

Rev Fr Hematol
14:471,
1974.
McGrath
JM, Stewart
GJ: The effects
of endotoxin
on
vascular
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J Exp Med 129:833,
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Maca RD, Fry GL, Hoak JC: New method
for detection
and quantitation
of circulating
platelet
aggregates.
Microvasc
Res 4:453, 1972.
Wilner
GD,
Nossel
HL,
LeRoy
EC:
Activation
of
Hageman
factor
by collagen.
J Clin Invest 47:2608,
1968.
Morrison
DC,
Cochrane
CG:
Direct
evidence
for
Hageman
factor
(factor
XII) activation
by bacterial
lipopolysaccharides
(endotoxins).
J Exp
Med
140:797,
1974.
Mason JW, Colman
RW: The role of Hageman
factor
in
disseminated
intravascular
coagulation
induced
by
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neoplasia
or liver
disease.
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Diath
Hemorrh
26:325,
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A: Neutrophil
of

neonatal

infec-

ACKNOWLEDGMENT

1974.
aspirate

19.

consi-

and understanding
newborn.

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We would
like to thank
Mrs. Phyllis
Silke for typing
the
manuscript
and Mrs. Wendy
Yacura
for clerical
assistance.
Also, we are grateful
for the technical
assistance
of Benjamin
Zipursky.
Elizabeth
J. Brown provided
valuable
advice.
We would
like to acknowledge
the tremendous
assistance
and encouragement
given to us by Dr. J. Sinclair
and his staff
in the McMaster
Neonatal
Intensive
Care Unit.

ARTICLES

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853

The Hematology of Bacterial Infections in Premature Infants


A. Zipursky, J. Palko, R. Milner and G. I. Akenzua
Pediatrics 1976;57;839
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
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Copyright 1976 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
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