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SIDS May Have Previously Unsuspected Pathogenesis
Norra MacReady
Medscape Medical News 2006. © 2006 Medscape
October 23, 2006 (Las Vegas) —
Sudden infant death syndrome (SIDS) may be a result of shock, metabolic
acidosis, and loss of homeostasis, according to findings presented here
at the annual meeting of the American Society for Clinical Pathology.
These data challenge the notion that respiratory
acidosis is the etiology of most, if not all, SIDS cases, the study's
author, Hazel L. McGaffey, MD, told Medscape. "Our belief is that it's
the metabolic acidosis that causes the heart to stop," said Dr.
McGaffey, a retired pathologist at Sacred Heart Hospital in Idaho
Falls, Idaho, and a former coroner.
It was in her capacity as coroner that Dr. McGaffey
conducted laboratory studies on SIDS cases that occurred between 1965
and 1987. Venous blood drawn from the superior sagittal sinus and
cerebrospinal fluid from the cisterna cerebellomedullaris was analyzed
from 40 infants who died between 1 and 8 months of age. All of the
samples were collected an average of 7 hours after the children were
last seen alive, and the results were compared with findings taken from
children and adults who died from other causes, including respiratory
and cardiac illness, acute trauma, and various chronic diseases.
The SIDS cases showed extreme acidosis, with an
average pH of 6.15 compared with an average of 6.65 among children who
died of respiratory causes. The SIDS bicarbonate buffer was decreased
to an average of 6.31 mEq/L compared with an average of 15.8 mEq/L
among cases of respiratory death.
These findings suggest that the brainstem
respiratory center may have shut down secondary to severe metabolic
acidosis, Dr. McGaffey said. "The elevation in carbonic acid [averaging
5.24 mEq/L in SIDS cases compared with 2.33 mEq/L in cases of
respiratory death] suggests that metabolic acidosis was the cause of
death," she explained. "As our findings indicate, respiratory acidosis
is associated with lower, not higher, carbonic acid."
Electrolyte levels were also severely imbalanced.
Extreme hyperkalemia was one of the most striking findings: the SIDS
babies had an average potassium concentration of 24.4 mEq/L compared
with a normal range of 4.1 to 5.3 mEq/L, according to Dr. McGaffey.
They also had hyponatremia, with an average sodium level of 127.9 mEq/L
compared with a normal range of 139 to 146 mEq/L; anoxia, as reflected
in a lactic acid level of 22.6 mMol/L; and the presence of nucleated red
blood cells. Elevated uric acid and blood urea nitrogen levels
suggested early renal failure.
"All of this may reflect metabolic acidosis that
began developing several days before death," Dr. McGaffey said. "If we
look for that in future cases, we may be able to prevent some deaths."
She cited one case of a 2-month-old male admitted with a low-grade
fever and a croupy cough. His pH was 7.2, and his HCO3- was
16.52 mEq/L. However, his potassium was slightly elevated, at 6.1
mEq/L, and he had anemia and a relative lymphocytosis, among other
findings. The patient was given penicillin, improved, and was
discharged, but his symptoms returned and about 10 days later he was
found dead in his crib. A full autopsy, including postmortem clinical
laboratory testing, revealed findings typical of SIDS at 7 to 8 days
after the original tests. "This suggests that the development of
metabolic acidosis in SIDS may take considerable time," Dr. McGaffey
said. "If we look for that, we might be able to prevent death."
"I think this is a very significant paper," said
Martin Kroll, MD, professor of pathology at the University of Texas
Southwestern School of Medicine in Dallas. "It certainly points a
finger in a different direction than we considered before," he told
Medscape.
Currently, healthy babies seldom undergo metabolic
testing after the first month of life, "but it is extremely doable,"
said Dr. Kroll, who was not involved in the study. "Maybe we should do
more laboratory tests on children. It certainly takes time for these
conditions to develop; with testing, we might be able to intercept the
problem."
This study did not receive commercial support. The
authors did not report any relevant financial relationships.
Am J Clin Pathol. 2006;126:636. Abstract 34;
presented October 19, 2006.