[Benign intracranial hypertension: an unrecognized complication of corticosteroid therapy]

BACKGROUND

Benign intracranial hypertension is due to an increased intracranial pressure of unknown cause. The initial symptoms, complications and associations with medical conditions are discussed.

CASE REPORT

A 6-year-old girl developed symptoms of benign intracranial hypertension following reduction of oral corticosteroid therapy. Laboratory studies and head-computed tomographic scan were normal. Examination of the optic discs showed bilateral papilledema and the cerebrospinal fluid pressure was increased. The patient was given prednisone therapy 1 mg/kg daily initially, associated with acetazolamide, and removal of 25 mL of cerebrospinal fluid. All the symptoms resolved and the treatment was gradually decreased. The child developed no further visual failure.

CONCLUSION

Benign intracranial hypertension with the risk of permanent visual loss is a complication underrecognized in children. All patients receiving large doses of the corticosteroids who complain of headache or blurring vision, particularly following a reduction of corticosteroid dosage, should have an ophtalmoscopic examination to exclude this complication.

A genetic syndrome associating dehydrated hereditary stomatocytosis, pseudohyperkalaemia and perinatal oedema

Dehydrated hereditary stomatocytosis is a haemolytic anaemia with an underlying impairment of monovalent cation transport. It is sometimes associated with pseudohyperkalaemia (e.g. an increase of kalaemia when blood is left at room temperature) or with perinatal ascites. We report a case in which dehydrated hereditary stomatocytosis, pseudohyperkalaemia and perinatal oedema coexisted, and were transmitted en bloc in a dominant fashion. Transfusions did not cure the oedema, that spontaneously receded after a few months. We assume that the various manifestations stemmed from one single altered locus, yet to be determined.

Neonatal hemolytic anemia due to inherited harderoporphyria: clinical characteristics and molecular basis

Porphyrias, a group of inborn errors of heme synthesis, are classified as hepatic or erythropoietic according to clinical data and the main site of expression of the specific enzymatic defect. Hereditary coproporphyria (HC) is an acute hepatic porphyria with autosomal dominant inheritance caused by deficient activity of coproporphyrinogen III oxidase (COX). Typical clinical manifestations of the disease are acute attacks of neurological dysfunction; skin photosensitivity may also be present. We report a variant form of HC characterized by a unifying syndrome in which hematologic disorders predominate: harderoporphyria. Harderoporphyric patients exhibit jaundice, severe chronic hemolytic anemia of early onset associated with hepatosplenomegaly, and skin photosensitivity. Neither abdominal pain nor neuropsychiatric symptoms are observed. COX activity is markedly decreased. In a first harderoporphyric family, with three affected siblings, a homozygous K404E mutation has been previously characterized. In the present study, molecular investigations in a second family with neonatal hemolytic anemia and harderoporphyria revealed two heterozygous point mutations in the COX gene. One allele bore the missense mutation K404E previously described. The second allele bore an A-->G transition at the third position of the donor splice site in intron 6. This new COX gene mutation resulted in exon 6 skipping and the absence of functional protein production. In contrast with other COX gene defects that produce the classical hepatic porphyria presentation, our data suggest that the K404E substitution (either in the homozygous or compound heterozygous state associated with a mutation leading to the absence of functional mRNA or protein) is responsible for the specific hematologic clinical manifestations of harderoporphyria.

[Myelodysplasia in children and mitochondrial cytopathies]

Sideroblastic anemia associated with vacuolization of haemopoietic precursors can be observed in some constitutional diseases associated with mitochondrial DNA deletion. In this condition, it is the haematological expression of a multi-tissue disorder. Haemopoiesis is polyclonal, without abnormality of nuclear DNA differing from the acquired idiopathic sideroblastic anemias which arise from a clonal transformed stem cell. This model of childhood polyclonal myelodysplasia can be observed in others myelodysplasias associated with constitutional polymalformative syndromes.

[Analgesics in pediatrics. Drugs for pain relief in children]

FUNDAMENTAL: Analgesia is a fundamental part of management as it helps avoid the morbid effects of pain itself and improves confidence so the child and his parents can accept more easily the diagnosis and proposed treatment. The World Health Organization has established a classification of analgesics. USE OF PLACEBOS: The placebo effect depends on several factors including anxiety, confidence, and the patient's- and prescriber's-expectations and convictions). It is observed early in the first years of childhood. Use of placebos is not recommended as a favorable reaction can be interpreted wrongly, disqualifying the complaint. EFFICACY LEVELS: For level 1, paracetamol has little toxicity and is easily managed for first line use; aspirin and nonsteroid antiinflammatory drugs can also be used if there are no contraindications. Level 2 drugs, codeine or dextropropoxyphene (which is not available in a pediatric formulation) are required for any manifestation of pain not relieved by level 1 drugs. Level 3 corresponds to strong central analgesics, mainly morphine. SPECIFIC PAIN: Antispasmodic agents in combination with paracetamol give partial relief of visceral pain without masking symptoms. Local anesthetics improve comfort without compromising safety. Neurogenic pain does not respond to usual analgesics and can be relieved with tricyclic antidepressors for burning sensations or antiepileptic drugs for fulgurant pain. TREATMENT-RELATED PAIN: Iatrogenic pain, by definition, must be systematically anticipated and prevented.

[Analgesics in pediatrics. Before prescribing: recognize and evaluate pain, reassure]

CAREFUL ASSESSMENT: In pediatric clinics, it has become habitual to prescribe analgesics in all painful situations. Particular attention must be paid to pain experienced by the child and obtaining objective evidence allowing valid assessment prior to treatment. ACUTE PAIN: Usually clearly expressed by crying screams, agitation, retraction and protection of the painful area, signs of acute pain are nonspecific and not proportional to its intensity. PROLONGED PAIN: Sadness and depression confound the expression of prolonged pain. Diagnosis may be difficult; an association between a potentially painful situation, pain relieving positions, and retraction behavior is specific. ESTABLISH CONFIDENCE: For both the child and his family, an atmosphere of confidence and a clear explanation of the lesions and their treatments are essential to break the viscious cycle of pain and anxiety. EXAMINING A CHILD WITH PAIN: Patience is the essence of examining children, facial mimics, reactions, movements and positions all provide essential information. ASSESSING PAIN INTENSITY: Using the visual analogue scale, VAS, children over 5 years of age can show where the pain is on a drawing of the body. For those under 5, questioning the family and looking for specific signs is an essential source of information. The DEGR scale can be used to score prolonged pain in children from 2 to 6 or 8 years of age.

[Myelodysplastic syndromes in children, Groupe d'étude des myélodysplasies de l'enfant de la Société d'hématologie et d'immunologie pédiatrique (SHIP)]

Myelodysplastic syndromes (MDS) in children constitute a heterogeneous disorder, including 'primary' MDS and MDS associated with constitutional abnormalities. The Franco-American-British (FAB) cytological classification for adults can be applied for childhood in 50 to 100% of the cases. The transformation into acute myeloblastic leukemia often occurs, but stabilisation or spontaneous regression of the disease may also be observed. The therapeutic decision is difficult because there is no predictive factor of the course of the disease. Allogenic bone marrow transplantation is the best curative option when treatment is necessary.

[Hereditary spherocytosis. Course and value of subtotal splenectomy]

BACKGROUND

Effectiveness of subtotal splenectomy, a procedure recently advocated as an alternative treatment to total splenectomy for patients with hereditary spherocytosis (HS), has been evaluated.

METHODS AND PATIENTS

Eighty-eight patients (74 children) with HS were included in this series. Clinical presentations ranged from asymptomatic cases to severe transfusion-dependent forms. Stunting of growth occurred in four cases; chronic fatigue was observed in 30 cases and cholelithiasis in 21 cases. Among the red cell indices measured by laser light scattering on Technicon H2, the most reliable for diagnosis was the abnormal percentage of hyperdense red cells (98% of HS patients). Osmotic gradient ektacytometry, used to measure membrane deformability and impairment of maximal deformability due to a reduction of erythrocyte surface, always showed the characteristic curves of HS.

RESULTS

Subtotal splenectomy was performed in 24 patients leading to a remnant spleen of about 25% of normal for age volume. This decreased the hemolytic rate while adequately sustaining the phagocytic function of the spleen (assessed by percentage of "pitted erythrocytes" and technetium 99n scans of the remnant). However, the observed reduction in hemolytic rate was not as extensive as that observed after total splenectomy (six cases) and subtotal splenectomy did not entirely prevent risk of cholethiasis (three cases).

CONCLUSION

This subtotal splenectomy (+/-cholecystectomy) has to be particularly considered for children with transfusion-dependent forms of HS, in order to obtain the benefits of increased hemoglobin levels without the pending risk throughout life of overwhelming post-splenectomy infections.

Occurrence of myeloproliferative disorder in patients with Noonan syndrome

We report four cases of Noonan syndrome associated with chronic myelomonocytic leukemia in childhood. These children shared some hematologic features: thrombocytopenia, splenomegaly in the first months of life, occurrence of chronic myelomonocytic leukemia without abnormalities of the initial bone marrow karyotype, and, in three cases, improvement of the hematologic disease. A common pathophysiologic process in such patients is suggested.

Effectiveness of partial splenectomy in hereditary spherocytosis

Total splenectomy eliminates the splenic destruction of erythrocytes with impaired deformability. However, concern has increased over the lifelong risk of overwhelming postsplenectomy infections in splenectomized patients, a risk reduced but not totally suppressed by appropriate prophylaxis. Partial splenectomy, as long as 80% to 90% of the enlarged spleen is removed and less than 25% of the normal spleen volume is retained, is a logical alternative, both preserving the phagocytic and immune function of the spleen and decreasing erythrocyte destruction. A 12-year experience has shown that subtotal splenectomy is efficient in decreasing hemolysis, although to a lesser extent than total splenectomy, with sustained results over years in most patients, and indirect evidence argues for the integrity of phagocytic function. Such a surgical procedure should be considered in transfusion-dependent infants with hereditary spherocytosis and in older patients with erythrocyte membrane defects, provided further follow-up confirms the experience of the past 12 years.

Idiopathic disseminated bacillus Calmette-Guérin infection: a French national retrospective study

OBJECTIVE

Disseminated bacillus Calmette-Guérin (BCG) infection after inoculation of live vaccine is considered to result from impaired immunity of the child. However, in half of the cases, regarded as idiopathic, no well-defined immunodeficiency condition can account for the infection. The objective of the present study is to report the prevalence, clinical features, associated infections, and outcomes of children with idiopathic disseminated BCG infection.

DESIGN

National retrospective survey during the period from 1974 through 1994 in France.

SETTING

All neonatology and pediatrics units in primary care and referral centers throughout France.

PATIENTS

Data were collected from 595 (82%) of 721 units, 377 (93%) of 407 centers, and 320 (93%) of 345 cities. Selection criteria included BCG infection, dissemination to at least two areas beyond the inoculation site, and no well-defined immunodeficiency condition. Sixteen children (8 girls and 8 boys), born to families unrelated to each other but often consanguinous (5 of 16) or abroad (5 of 16).

RESULTS

The minimal prevalence rate was estimated at 0.59 cases per 1 million vaccinated children born in France. Clinical features included fever and cachexia, disseminated BCG infection to lymph nodes (15 of 16), skin (13 of 16), soft tissues (11 of 16), lungs (11 of 16), spleen (11 of 16), liver (11 of 16), and bones (9 of 16). Eight children had associated or subsequent severe opportunistic infection (50%), with either nontyphi Salmonella enterica serotypes (7 of 16) or Mycobacterium abscessus (1 of 16). The outcome was poor: 8 children (50%) died; the cause of death was BCG infection for most children (7 of 8); 8 survived until the last follow-up (50%).

CONCLUSIONS

Idiopathic disseminated BCG infection is a rare but severe complication of BCG vaccination. The infection probably results from an as yet unknown genetically determined immunodeficiency condition that affects the killing of intracellular bacteria such as BCG and Salmonella.

Myelodysplasia in childhood may be a polyclonal disease

Myelodysplasia in childhood can be associated with constitutional abnormalities. Two main situations can be observed: constitutional diseases such as Down's Syndrome may be the first step of a malignant stem cell transformation leading to monoclonal hematopoiesis. However, in other situations such as mitochondrial cytopathies or other polymalformative syndromes, myelodysplasia may simply be the hematological expression of a multi-tissue constitutional disease. In such cases, the bone marrow karyotype is usually found to be normal and, in affected females, clonality studies show a polyclonal pattern. Clonality assessment should be, when possible, a mandatory step before any major therapeutic decision during the course of childhood myelodysplasia.

[Sarcoidosis with hematologic involvement and hypogammaglobulinemia]

BACKGROUND

Hematological changes are uncommon in childhood sarcoidosis.

CASE REPORT

Case 1. This patient developed severe hemolytic anemia associated with splenomegaly at the age of 11 months. A second episode of hemolysis was seen at the age of 6 years; it was associated with thrombocytopenia and hypogammaglobulinemia. A partial splenectomy permitted histological diagnosis of sarcoidosis that was confirmed by elevated angiotensin-converting enzyme level, and subsequently developement of pulmonary involvement. Case 2. This boy suffered from autoimmune hemolytic anemia and thrombocytopenia associated with splenomegaly at the age of 3 years. At the age of 7 years, he had splenomegaly, enlarged cervical and lomboaortic lymph nodes and hypogammaglobulinemia. Diagnosis of sarcoidosis was made from lymph nodes and spleen biopsies after splenectomy; the patient had increased angiotensin-converting enzyme concentration, and subsequently developed specific renal involvement.

CONCLUSION

Association of hemolytic anemia, thrombocytopenia, hypogammaglobulinemia and splenomegaly should suggest the diagnosis of sarcoidosis and could be considered as part of the disease spectrum.

Induction chemotherapy followed by allogeneic bone marrow transplantation or aggressive consolidation chemotherapy in childhood acute myeloblastic leukemia. A prospective study from the French Society of Pediatric Hematology and Immunology (SHIP)

In the LAME89/91 protocol, children with acute myeloid leukemia (AML) who achieved complete remission (CR) after induction chemotherapy, were treated either with allogeneic bone marrow transplantation (BMT) if they had an HLA-compatible related donor or with chemotherapy including high-dose cytarabine. The objectives of this study were to describe the overall results of this strategy and to compare the two post-remission arms. Two hundred and thirty-one children were enrolled in the protocol. Induction chemotherapy consisted of a combination of cytarabine and mitoxantrone. A CR was achieved in 204 children (88%).

Erythroblastic and/or megakaryoblastic leukemia in Down syndrome: treatment with low-dose arabinosyl cytosine

PURPOSE

We report here the clinical response to low-dose arabinosyl cytosine (Ara-C) in seven children with Down syndrome (DS) and acute leukemia in which blast cells express markers of erythroid and/or megakaryoblastic lineages. Following an initial course of treatment with Ara-C, complete remission was obtained in all seven patients. Maintenance therapy with Ara-C was continued during complete remission. Four patients subsequently relapsed; the three others are disease-free. Based on these data, we suggest that when conventional therapy is contraindicated by associated malformations, low-dose Ara-C can be used for treating DS patients with erythroblastic or megakaryoblastic leukemia. The aim of this study was to assess the efficacy of low-dose Ara-C in treating megakaryoblastic and/or erythroblastic leukemia associated with DS.

PATIENTS AND METHODS

Seven patients with DS presented with leukemia in which blast cells displayed early markers of the erythroblastic and/or megakaryoblastic lineage. Low-dose subcutaneous Ara-C (10 mg/m2 two times per day) was given for 21 days as induction therapy, followed by a 5-10-day course each month for 2 years as a maintenance treatment.

RESULTS

Low-dose Ara-C treatment resulted in complete remission in all seven patients and in long-term disease-free survival in three patients.

CONCLUSION

In cases in which conventional chemotherapy is contraindicated, low-dose Ara-C should be considered as a therapeutic alternative for treatment of DS-associated erythroblastic or megakaryocytic leukemia.

[Encephalopathy induced by arterial hypertension: clinical, radiological and therapeutical aspects]

BACKGROUND

Neuroradiological features of hypertensive encephalopathy are not yet well-known.

PATIENTS AND METHODS

The clinical manifestations, neuroradiological aspects and treatment of four patients suffering from hypertensive encephalopathy were studied; special attention was paid to manifestations presented by one patient which appeared representative of the usual manifestations of hypertensive encephalopathy.

RESULTS

The main clinical features were visual disturbances (n = 4); altered consciousness (n = 2) and seizures (n = 3). Visual disturbances resulted from cortical lesions (n = 4) associated with optic nerve damage and retinopathy (n = 2). Cerebral imaging showed low density images (CT scan) and hypersignal (MRI, T2 sequence) located in parieto-occipital cortical ribbon and adjacent white matter from the first 24 hours following the onset of neurologic symptoms. In the studied patient, the abnormal images resolved within 1 month after the onset of the disease. Unilateral infarction of the anterior visual pathway affected two patients in whom: 1) hypertension remaining undetected for a long time was revealed by neurological signs; 2) visual impairment was preceded by an hypotensive episode induced by antihypertensive therapy.

CONCLUSIONS

Neuroradiological features of hypertensive encephalopathy are useful in establishing the diagnosis. A gradual reduction of blood pressure could prevent the risk of visual complications.

[Pain in children: specific aspects]

Childhood pain is still poorly understood, neglected and undertreated. The neurophysiological mechanisms of nociception exist before birth. The experience of pain develops during childhood. Its symptomatology has been detailed: sharp emotional reactions and signs of stress during acute pain, antalgic posture, psychomotor atony and denial when pain is prolonged. Specific tools for evaluation are available. Treatment generally calls for the use of peripheral analgesics, and increased intensity of pain can require administration of morphine.

Refractory anaemia and mitochondrial cytopathy in childhood

We report two cases of childhood myelodysplasia (MDS) related to a mitochondrial (mt) cytopathy that illustrate the difficulty in recognizing such disorders in patients with solely haematological signs. Both patients have refractory anaemia with ring sideroblasts and vacuolization of haemopoietic precursors. These cytological features are similar to those observed in Pearson's disease, recently identified as a mitochondrial disease, and are strongly suggestive of a mitochondrial enzyme defect. The diagnosis of mitochondrial cytopathy was established on Southern blotting of mt DNA, showing a mt DNA deletion, or on the impairment of the respiratory chain enzyme activities. The absence of cytogenic abnormalities, and the polyclonal pattern of peripheral neutrophil and lymphocyte fractions, suggest that, in mt cytopathies, MDS cannot be considered as a truly malignant disorder.

Mastoiditis, meningitis and venous sinus thrombosis caused by Fusobacterium necrophorum

The authors report a case of septic venous sinus thrombosis (VST) and meningitis occurring as an early complication of mastoiditis caused by Fusobacterium necrophorum. CT scan was normal, and cerebral angiography was required to diagnose the VST. The evolution was favourable with appropriate antimicrobial therapy and steroids.

[Congenital malaria. A case observed in twins born to an asymptomatic mother]

Even in endemic zones, congenital malaria, first described in 1876, is rarely encountered. The incidence has greatly increased however over the last 10 years suggesting several diagnostic problems. We observed a case of infected twins born to an asymptomatic mother which would throw some light on the pathophysiology involved in congenital transmission. A 2-month old infant was hospitalized for surgical cure of an umbilical hernia. Haemolytic anaemia (6.3 g/dl) and fever (39 degrees C) were observed during the postoperative period. A wide spectrum antibiotherapy was prescribed but the temperature remained at 39 degrees C. A blood swab cultured one week after the operation revealed Plasmodium falciparum. The infant's twin sister was in apparently good health but was also found to be anaemic (6.1 mg/dl Hg) and a blood sample was positive for P. falciparum. For the mother, the search for parasites was negative. Serology tests performed at diagnosis revealed anti-P. falciparum antibodies at 1/1600, 1/3200 and 1/6400 in the infant, his twin sister and the mother. Outcome was favourable. The mother had arrived in France from Togo 14 months earlier and had not returned to an endemic zone. She had had frequent episodes of fever in Togo and had taken quinine, but no episode of fever had occurred during the pregnancy or delivery. This twin case of vertical mother-infant transmission is the equivalent to transfusional malaria since red cells pass the placental barrier near the end of pregnancy, even when no placental lesion exists. Congenital transfusional malaria must however be dissociated from congenital infective malaria resulting from early primoinfection in endemic areas.