Early Exchange Transfusion in Critical Pertussis: A Case Report Supporting Timely Intervention.

BACKGROUND: Critical pertussis is a rapidly progressive, life-threatening illness in infants, often presenting with hyperleukocytosis, respiratory failure, and hemodynamic instability. Mortality remains high despite supportive advances, and no standardized guidelines exist to guide the use of exchange transfusion in this setting. OBJECTIVE: To describe the outcomes of early exchange transfusion in infants with critical pertussis managed in a high-acuity tertiary PICU in Kuwait and to advocate for the development of a standardized national protocol. METHODS: This prospective case report includes three infants with PCR-confirmed Bordetella pertussis infection admitted between January and December 2024 to the Pediatric Intensive Care Unit (PICU) of New Jahra Hospital, Kuwait's busiest tertiary-level center. The decision to initiate exchange transfusion was based on consensus clinical assessment integrating clinical status and laboratory progression. Once the decision to proceed was made, double-volume exchange transfusion was performed according to a unit-specific procedural protocol developed within our institution. Clinical data, laboratory trends, and short-term outcomes were reviewed. RESULTS: All infants presented with severe respiratory failure, marked hyperleukocytosis (> 30-60 × 109/L), and evolving hemodynamic instability. Exchange transfusion performed within 2-4 days of admission led to prompt leukoreduction, improved perfusion, and clinical stabilization. All survived to discharge and remained well at 6-week follow-up. Thrombocytopenia occurred following exchange transfusion and resolved with supportive care. Seizures and iatrogenic opioid withdrawal occurred during the PICU course in Cases 1 and 2 and were not considered complications directly attributable to exchange transfusion. National feedback from PICU unit heads highlighted broad support for protocol standardization. CONCLUSION: Early exchange transfusion, guided by evolving clinical severity and laboratory trends, may contribute to favorable outcomes in infants with critical pertussis when considered before refractory pulmonary hypertension develops. These cases support timely recognition and intervention while underscoring the need for standardized national practice, maternal Tdap immunization, and strengthened disease surveillance.