Gastric ganglioneuroblastoma: a rare finding in an infant with multifocal ganglioneuroblastoma

PURPOSE

This report describes a female infant with stage 4 multifocal ganglioneuroblastoma with gastric involvement.

PATIENT

The patient had a right cervical tumor, a left posterior mediastinal tumor, bilateral adrenal tumors, and bony and bone marrow metastases. The tumor cells were diploid and lacked N-myc gene amplification. The gastric involvement, which did not produce clinical symptoms, was only detected by meticulous exploration during laparotomy.

RESULTS

Our patient achieved only a partial response to alternating cycles of cyclophosphamide, vincristine, and adriamycin; and etoposide and cisplatin. She currently has stable, unresectable disease with elevated catecholamines.

CONCLUSIONS

Multifocal ganglioneuroblastomas may arise from either neuroblastic rests or aberrant deposits of neuroblasts. The latter mechanism may have accounted for our patient's gastric tumor. Patients with multifocal ganglioneuroblastomas warrant meticulous radiographic and surgical evaluation to completely document the full extent of disease, and to ensure appropriate staging and therapy.

Langerhans cell histiocytosis associated with partial DiGeorge syndrome in a newborn

PURPOSE

We report the unrecognized association of Langerhans cell histiocytosis (LCH) with partial DiGeorge syndrome.

PATIENT AND METHODS

A 7-week-old infant with endocrine and immunologic characteristics of DiGeorge syndrome displayed multisystem involvement of Letterer-Siwe disease at birth.

RESULTS

Despite vigorous medical support and chemotherapy, she died at 9 months of age with multisystem failure.

CONCLUSIONS

This case supports the role of the thymus n the pathogenesis of LCH.

Gastrointestinal problems in a child with dyskeratosis congenita

We describe a pediatric patient with dyskeratosis congenita, whose symptoms included abdominal pain, vomiting, dysphagia, and hematochezia. Gastrointestinal symptom are prominent in this rare genetic disorder.

Confirmation of Borrelia burgdorferi spirochetes by polymerase chain reaction in placentas of women with reactive serology for Lyme antibodies

The purpose of our study was to determine whether Borrelia burgdorferi spirochetes were present in placentas of asymptomatic women with reactive Lyme serology using a silver stain, and to confirm the identity of the spirochetes by polymerase chain reaction (PCR). Sixty placentas of asymptomatic women with ELISA-positive or-equivocal serology for Lyme antibodies during pregnancy were examined for spirochetes using a silver stain. The results of the ELISA serology were confirmed by Western blot analysis. PCR amplification for B. burgdorferi was performed on placentas identified to have spirochetes and on a group of placentas negative for spirochetes. Spirochetes were identified by silver staining in 3 (5%) of the 60 placentas. PCR confirmed B. burgdorferi nucleotide sequences in 2 of the placentas. The 5 women had equivocal Lyme ELISA and negative syphilis serology. The results of the Western blot analysis were negative in 2 cases and indeterminate in 1 case. Six controls were negative for spirochetes by silver staining and PCR. A normal perinatal outcome was observed in all cases. Spirochetes identified in placental tissue of pregnancies with reactive Lyme serology were confirmed by PCR to be B. burgdorferi. There was no relationship between the presence of placental spirochetes and the results of Lyme serology or the pregnancy outcome.

Spontaneous pneumothorax in children with AIDS

The incidence of pneumothorax in HIV-infected children has not been reported. In adults with AIDS, pneumothorax has been described exclusively in association with Pneumocystis carinii pneumonia (PCP). We report the cases of three children with AIDS, one with lymphoid interstitial pneumonitis (LIP) without evidence of PCP and two with PCP, all of whom developed spontaneous pneumothorax (SP). On presentation, none of the children had any risk factors for the development of pneumothorax, but all had radiographic evidence of subpleural cystic lesions and bilateral pleural adhesions. None of the patients responded to conservative medical management, which included chest tube thoracostomy and chemical pleurodesis. Two patients underwent pleurectomy that resulted in resolution of the pneumothorax. Both patients with PCP who developed pneumothorax died, but the patient with LIP and SP has had no recurrences of any serious respiratory problems 3 years after pleurectomy and excision of the intrathoracic cysts.

Hypertrophic gastropathy in a newborn: a case report and review of the literature

A newborn with hypoalbuminemia, hematochezia, and hypertrophic gastropathy is described. These features are similar to those reported in association with prostaglandin therapy in newborns, as well as those described in so-called Ménétrier's disease. Very few cases of hypertrophic gastropathy have been reported in children and fewer still verified histologically; only three other cases have been reported in newborns. The clinical and pathologic features of hypertrophic gastropathy in children, as well as its close association with eosinophilic gastroenteritis and with prostaglandin therapy, are discussed.

Doppler velocimetry, placental morphology and outcome in insulin-dependent diabetes

The purpose of this study was to determine the underlying cause of abnormal umbilical artery Doppler velocimetry in pregnancies complicated by insulin-dependent diabetes, by evaluating placental morphology and correlating Doppler results with pregnancy outcome. Our study population consisted of 14 pregnancies with normal Doppler results and 11 pregnancies with abnormal Doppler results. Quantitative placental examinations were performed. Maternal and perinatal characteristics were analyzed. Infants from the abnormal Doppler group had a statistically significantly higher incidence than those from the normal Doppler group of hyperbilirubinemia, Cesarean delivery for fetal distress, and neonatal intensive care stay of 2 or more days. Women with abnormal Doppler results delivered earlier (36 vs. 38 weeks) and had infants of lower birth weight (3079 vs. 3629 g). They were also three times more likely to have poor glycemic control (relative risk = 3.2; p = 0.0067). The placentae of both groups showed no statistically significant differences in placental weight, number of tertiary stem villi, number of small muscular arteries, or mean arterial width. Our findings suggest a functional rather than structural placental process as the cause of the abnormal Doppler results in pregnancies complicated by diabetes. An association between glycemic control and Doppler velocimetry is suggested.

Coincidence of congenital toxoplasmosis and biliary atresia in an infant

A 4-week-old infant presenting with neonatal cholestasis was found to have congenital toxoplasmosis and biliary atresia. This is the first patient in which their coincidence is reported. Because biliary atresia can coexist with either congenital infection or inborn errors of metabolism, evaluation for an obstructive etiology of jaundice in infants with a recognized cause of intrahepatic cholestasis is necessary.

Localized Aspergillus infestation in primary lung carcinoma. Clinical and pathological contrasts with post-tuberculous intracavitary aspergilloma

Saprophytic infestation with Aspergillus was observed in pathologic specimens of primary squamous cell lung carcinoma. In one case, the fungus grew in cystic scarred parenchyma and bronchi distal to an obstructing carcinoma of a segment bronchus. In the other, fungi colonized the inner surface of a peripheral cavitary carcinoma. Neither patient had roentgenographic evidence of aspergilloma and neither experienced severe pulmonary hemorrhage or other complications attributable to the presence of fungus. Although both specimens showed colonizing growth within the abnormal air spaces, in neither had the colonies detached to form a separate intracavitary fungus ball. These patients, and eight patients with similar lesions reported in the literature, demonstrate that Aspergillus colonization of a lung neoplasm frequently lacks one or both of the features characteristic of post-inflammatory intracavitary aspergilloma, a loose fungus ball and antifungal serum antibodies. No patient, to date, has developed massive hemorrhage as a complication of this lesion.

Combined occurrence of chyloperitoneum and chylothorax after surgery and chemotherapy for Wilms' tumor

Chyloperitoneum is an extremely rare complication of abdominal surgery in children and a combined occurrence of chylothorax and chyloperitoneum after abdominal surgery has never been reported in children. Chylous ascites usually occurs as a result of operative trauma to the thoracic duct, cisterna chyli, or its tributaries. About one third of all patients with chylous ascites after retroperitoneal lymph node dissection also develop secondary chylothorax. Diaphragmatic defects have been shown to be responsible for the occurrence of chylothorax secondary to chyloperitoneum. Congenital diaphragmatic weakness may result in evagination of the peritoneum causing diaphragmatic blebs, the rupture of which results in the movement of the peritoneal fluid into the pleural cavity. In the authors' patient, the rent in the diaphragm that occurred during surgery was probably responsible for the chylothorax. The role of chemotherapy, if any, in the pathophysiology of this complication is unknown. Total parenteral nutrition (TPN) is a simple and effective treatment for postoperative chylous effusions. Surgical treatments such as abdominal exploration for the repair of leaking lymphatics and peritoneovenous shunt should be reserved for patients who fail TPN.

Campylobacter pylori-related gastrointestinal disease in children. Incidence and clinical findings

Over a one-year period, 95 children and adolescents presenting with epigastric pain and/or vomiting, and without associated risk factors for development of peptide disease, underwent endoscopic antral biopsies for pathologic diagnosis and to detect presence of Campylobacter ss. pylori (C. pylori). Additional biopsies of the esophagus, stomach, and duodenum were obtained for histologic evaluation. C. pylori was identified in 16 patients (16.8%), all of whom had evidence of acute and/or chronic gastritis. Significant discriminating factors between C. pylori-positive and -negative subjects included age at presentation (positive vs negative = 14.6 vs 9.9 years, P less than 0.01), biopsy-confirmed gastritis (100% vs 30.4%, P less than 0.001), and diagnosis of duodenitis alone (0% vs 46.8%, P less than 0.001). Risk for bacterial colonization was significantly higher in the presence of endoscopic gastritis (P less than 0.001). Among C. pylori-positive patients, none responded to standard antiulcer therapy (H2-receptor antagonists, antacids). Symptomatic and histologic remission was achieved utilizing combined therapy with bismuth subsalicylate and antibiotics. Seven of 79 C. pylori-negative patients with biopsy-proven gastritis who responded poorly to antisecretory therapy had the organism identified in follow-up antral biopsies; these patients improved clinically following treatment for C. pylori. These data suggest that C. pylori is a significant factor in the etiology of upper gastrointestinal tract inflammatory disease in pediatrics, and presence of the organism should be evaluated, particularly in children with evidence of acute and/or chronic gastritis.

Doppler velocimetry and placental disease

Quantitative placental examinations were performed on 47 women who had Doppler flow velocity studies of the umbilical artery during their pregnancy. The systolic-diastolic ratio of the umbilical artery was used as the measurement parameter to divide the study population into two groups. Group 1 consisted of women with normal systolic-diastolic ratios (systolic-diastolic less than 3), and group 2 consisted of women with an elevated systolic-diastolic ratio (systolic-diastolic greater than or equal to 3). The group with an increase in systolic-diastolic ratio had more perinatal complications as demonstrated by two stillbirths, a higher incidence of cesarean deliveries for fetal distress, and more admissions to the neonatal intensive care unit. Significant differences were found when gestational age at delivery, placental weight, birth weight, and the number of small muscular arteries in the placenta were compared. Since gestational age may have accounted for the difference in placental findings, patients were matched for gestational age. The placental weights were comparable, but there were fewer small muscular arteries in those patients with an increase in systolic-diastolic ratio (p less than 0.001). In addition, when these findings were examined to determine the influence of diminished uterine flow velocity, none was found.

Severe intrahepatic cholestasis in patients treated with recombinant interleukin-2 and lymphokine-activated killer cells

Immunotherapy with recombinant interleukin-2 (rIL-2) and lymphokine-activated killer cells (LAK) has become a new form of therapy that has been shown to induce remissions in patients with renal cell carcinoma and melanoma. Despite encouraging results, this form of therapy has been associated with increasing toxicity, often requiring therapy in an intensive-care unit. In this report severe intrahepatic cholestasis occurred in two patients receiving rIL-2 and LAK cells. This form of cholestasis appeared to be directly related to rIL-2 administration at a doses of 2 x 10(6) U/m2 and 3 x 10(6) U/m2 t.i.d. A liver biopsy showed moderate hepatocellular bile stasis, with lobular and portal inflammation. All other studies for potential cause of this cholestasis were negative, including studies for metastatic disease. When therapy was discontinued, evidence for cholestasis and bile stasis resolved. We conclude that rIL-2 is a drug with a potential to induce severe hepatic injury that is reversible upon cessation of therapy with rIL-2. Further care should be exercised when rIL-2 is administered to patients with abnormal liver function.

Acrocallosal syndrome: additional manifestations

The acrocallosal syndrome (ACS) is a probable autosomal recessive condition of macrocephaly, craniofacial and hand and foot abnormalities, absence of the corpus callosum, and mental retardation. This patient had characteristics of the ACS but also had a severe congenital heart defect and other visceral malformations. After comparing the ACS with and contrasting it to other disorders, we concluded that the internal organ abnormalities found in this patient probably represent further manifestations of the ACS.

Presacral mesenchymoma: a case report

A 4-year-old girl with a presacral benign mesenchymoma is reported. The nature of the tumor was not recognized preoperatively or intraoperatively. There was evidence of pericapsular infiltration of the soft tissues of the pelvis but not signs of malignancy. A follow-up examination after 3 months indicates that the patient has no clinical evidence of recurrence. Review of the English literature shows the rarity of benign mesenchymoma in childhood and the lack of reports of its occurrence in the pelvis.

Partial trisomy 6q: case report with necropsy findings

A male infant with partial trisomy 6q is described. This patient shares features with 12 previously reported cases including hypertelorism, cleft soft palate, bow shaped mouth, micrognathia, short, laterally webbed neck, clubbing of hands and feet, syndactyly, and growth retardation. In addition, visceral anomalies less frequently reported are described. These observations may extend the phenotypic characterisation of the trisomy 6q syndrome.

Congenital bilateral absence of the fifth ray and vaginal atresia

We have studied an infant with respiratory distress, absent fifth rays of the hands, and hydrometrocolpos. Congenital absence of the fifth ray of the hand is a rare malformation. In some syndromes the ulnar defects are symmetrical; however, as an isolated anomaly the defects are usually asymmetric. This patient's malformations appear to be unique in that the ulnar ray was affected bilaterally, with an associated genital malformation.

Glomerulonephritis in congenital cytomegalic inclusion disease

Except for renal transplant recipients, glomerulonephritis has only very rarely been associated with renal cytomegalovirus (CMV) infection. The kidneys of five infants with congenital cytomegalic inclusion disease, including renal infection, were examined at autopsy. Two of the infants had glomerulonephritis. The younger, a 4-month-old female, had diffuse proliferative and necrotizing glomerulonephritis; virus was present in nuclei and cytoplasm of glomerular endothelial cells and, possibly, in leukocytes as well. There were no electron-dense deposits. The other infant, a 5-month-old male, had diffuse mesangial and focal segmental proliferative and sclerosing glomerulonephritis; electron-dense mesangial deposits were seen ultrastructurally. Three additional infants (a newborn male, a 2-day-old male, a 6-week-old female), all with CMV in tubules and one with a single glomerular inclusion, had only rare glomerular abnormalities, i.e., mesangial proliferation in less than 10 per cent of glomeruli (one infant) and segmental sclerosis in less than 1 per cent of glomeruli (all three infants). Thus, congenital renal CMV infection was associated with proliferative glomerulonephritis in the two infants who survived the longest. The three with shorter survival times had only minor glomerular alterations.

Characterization of tissue amyloid by immunofluorescence microscopy

Immunohistochemical classification of amyloid type was possible in 44 of 50 (88%) patients as judged by the concordance of immunofluorescence, clinical, serum, and urine immunoelectrophoresis, and bone marrow data. In frozen tissue sections incubated with a panel of antisera monospecific for immunoglobulin heavy chains, kappa and lambda light chains, and amyloid-A-related protein, the amyloid was classified as AL in 20 and AA in 24. In 6 patients the amyloid could not be classified because of the absence of reactivity in 2 and overlap staining in 4. The findings indicate that routine immunofluorescence examination of diagnostic biopsies is an important adjunct in the classification of amyloid.