Sepsis: A cause of sudden unexpected death and a working definition
NT Dlamini, S Band, A Tabor, M Samuels. Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke on Trent & Walrus Respiratory Unit, Great Ormond Street Hospital, London
Some cases of sudden unexpected death in infants and children (SUDIC) occur from fulminant sepsis. There is no agreed definition for accepting this mechanism of death within SUDICs.
To characterise the history, Emergency Department (ED) and post-mortem (PM) findings in children who died unexpectedly and in whom the likely diagnosis was sepsis and to make a working definition for Sudden Unexpected Death (SUDIC) due to Sepsis.
We reviewed all SUDIC cases between 2008 and 2016 listed on the database for the local Child Death Overview Panel, and identified those thought to be due to natural causes. We then collected clinical details alongside the ED and PM findings to characterise which deaths were likely to be due to severe and overwhelming infection. Our early management of SUDIC includes the collection of samples as soon as possible after death for investigation of infection.
Over 8 years, there were 160 cases designated as SUDIC due to natural causes, of which 17 (11%) were from infection-related causes. We examined complete records for 12 children (7 girls), aged 4 months to 12 years (median 26 months). Three (25%) had preceding signs suggestive of infection, but insufficient to diagnose sepsis. Five of the other 9 children died from beta haemolytic group A streptococcus sepsis, one from beta haemolytic group B streptococcus sepsis, one from staphylococcus aureus sepsis, and one from Haemophilus influenza sepsis. In the remaining child, the cause of death was unascertained but ‘likely sepsis secondary to streptococcal infection’.
Eight children were unwell for 48 hours, with a median duration of symptoms of 24 hours. Six had medical review before death. Symptoms included: fever, cough, coryza, unsettled, lethargy, vomiting and diarrhoea and all but one were managed as viral illnesses.
Lethal sepsis can progress rapidly, but be difficult to distinguish from viral infection at onset. A working definition for SUDIC-sepsis includes: sudden death with i) prodromal symptoms; ii) a likely pathogen in a normally sterile site; and, iii) evidence of inflammatory reaction (such as raised CRP, WCC and histological changes).