Post-hepatitic aplastic anaemia in children in Taiwan, a hepatitis prevalent area

Aplastic anaemia is a rare but serious complication of hepatitis, and hepatitis is an unusual cause of aplastic anaemia in children in the West. However, the relative frequencies of acquired aplastic anaemia in children in Taiwan, a hepatitis prevalent area, differ from those in the West, in the very high frequency of post-hepatitic aplastic anaemia (23.9% of all cases of aplastic anaemia). This may account for the higher incidence of aplastic anaemia in children in Taiwan. Although the prognosis of post-hepatitic severe aplastic anaemia was very poor, the present study using bone marrow transplantation, antithymocyte (or antilymphocyte) globulin, high-dose methylprednisolone and cyclosporin, etc., has improved the response rate and the survival.

An improved technique for experimental penetrating keratoplasty in rabbits

Penetrating keratoplasty is difficult to perform, especially for the beginning ophthalmologist or corneal surgeon. This investigation describes, step by step, a simplified technique of performing experimental keratoplasty on rabbit eyes. Use of this method resulted in 20 of 24 (83%) rabbit eyes maintaining technically successful clear grafts without anterior synechiae or angle-closure glaucoma for up to 3 months postoperatively.

Acute abdomen in childhood leukemia

With the continuing advancement in the treatment of childhood leukemia and the lengthened survival of these patients, an increased incidence of abdominal complications has been observed. A retrospective analysis of 364 patients with leukemia treated at the National Taiwan University Hospital from January 1977 through April 1988 was undertaken. Eleven patients (3.0%) developed abdominal complications during their course of disease, including acute appendicitis, intussusception, intestinal perforation, ovarian cyst rupture, etc. All of these patients had abdominal complications during the initial presentation or relapse of leukemia, and 9 (82%) of them had just received chemotherapy. Ten patients (91%) had thrombocytopenia and 7 (64%) had leukopenia. Blood cultures were positive in 5 patients (45%), and gram-negative enteric bacilli were isolated in 4 of them. All 5 septicemic patients had leukopenia or neutropenia. The clinical manifestations were nonspecific and were often masked. Most of the complications occurred in the right lower abdominal structures. Of the 7 children treated surgically, 3 had long term survival. Among the 4 patients who did not receive an operation, only 1 survived for more than 4 weeks. The mean length of survival tended to be longer in patients with additional surgical treatment. Prompt diagnosis and early aggressive treatment, under modern supportive facilities, appear to offer a more favorable outcome.

Terrien's marginal degeneration: corneal topography

Computer-assisted corneal topographic analysis was used to evaluate the corneal contour of four patients with Terrien's marginal degeneration. The corneal topography in these patients was characterized by flattening over the areas of peripheral thinning produced by the disorder. When thinning was restricted to the superior and/or inferior areas of the peripheral cornea, there was a relative steepening of the corneal surface approximately 90 degrees away from the midpoint of the thinned area. This resulted in high against-the-rule or oblique astigmatism characteristic of the disorder. This common pattern is attributable to the frequency with which the superior and/or inferior peripheral cornea is preferentially involved in Terrien's marginal degeneration. In some patients, the central corneal topography may remain relatively spherical if the area of thinning is small or if the disorder extends around the entire circumference of the cornea.

Topographic changes that occur with 10-0 running suture removal following penetrating keratoplasty

Twelve eyes undergoing penetrating keratoplasty with a double-running suture technique had corneal topographical analysis immediately before and one month after 10-0 suture removal. Substantial changes in astigmatism were evident following suture removal. Twenty five percent of eyes showed a decrease of 1 D, 33% of eyes showed a decrease of 3 D, 8.3% of eyes showed an increase of 1 D, 8.3% of eyes showed an increase of 2 D, 16.6% of eyes showed an increase of 3 D, and 8.3% of eyes showed an increase of 4 D of astigmatism following suture removal. The mean corneal astigmatism did not show a significant change from a mean of 5.3 D after suture removal. There was less individual variation of spherical corneal power following suture removal. Thirty three percent of eyes showed a decrease of 1 D, 33% of eyes showed a decrease of 2 D, 8.3% of eyes showed a decrease of 3 D, 18.3% of eyes showed an increase of 1 D, and 6.6% of eyes showed an increase of 2 D of spherical power following suture removal. The surface asymmetry index (SAI), a centrally weighted measure of corneal surface irregularity, decreased significantly (P less than 0.04) from a mean of 1.17 before suture removal to a mean of 0.93 after suture removal. These results suggest that surface irregularity may be decreased following the removal of a single running 10-0 nylon suture following penetrating keratoplasty.

Dacryocystography: comparison of water-soluble and oil-based contrast agents

Dacryocystography has been widely used in the assessment of the nasolacrimal duct system, particularly in patients with epiphora. Our study was undertaken to evaluate image quality and level of patient discomfort during examinations with water-soluble contrast agents (iohexol [Omnipaque 240], iopamidol [Isovue 200 and 300], and 52.7% diatrizoate meglumine and 26.9% iodipamide meglumine [Sinografin]) compared with the iodized oil-based contrast agent Lipiodol. Fifty-five dacryocystograms were obtained from 41 consecutive patients. The procedure was performed first with a water-soluble contrast agent, then repeated with Lipiodol. A distention technique was used with conventional radiography. Patients were asked to evaluate their level of discomfort (none, mild, moderate, severe). The images were evaluated separately by two radiologists, blinded to which water-soluble agent was employed, and the images were graded on a five-point scale. Images obtained with Lipiodol were significantly better than those with other agents (P less than .02), and image quality deteriorated as iodine concentration decreased. Use of Isovue 300 and Sinografin produced significantly more patient discomfort (P less than .03) than the use of other agents. The authors conclude that, in most instances, Lipiodol is the contrast agent of choice with regard to both highest level of patient comfort and greatest conventional radiographic image quality among the agents compared.

Penetrating keratoplasty in rabbits induces latent HSV-1 reactivation when corticosteroids are used

The increased incidence of corneal graft failure in patients with herpes simplex virus (HSV) keratitis may be due in part to reactivation of latent HSV following surgical corneal trauma and postoperative corticosteroid therapy. To determine the onset, frequency, and nature of HSV recurrences following penetrating keratoplasty (PKP), 21 HSV type 1 (HSV-1) latently infected rabbits underwent unilateral autograft PKP. Opposite unoperated eyes served as HSV-1 latently infected controls. Corneal autografts were performed so that immunologic graft rejection would not be confused with recurrent HSV-1 stromal disease. After PKP, 11 of the 21 eyes were treated with dexamethasone. Ocular cultures and slit-lamp examinations were performed daily for the first postoperative 8 days and every other day thereafter for 82 days. Nine (82%) of the 11 dexamethasone-treated PKP eyes, 2 (20%) of the PKP eyes not treated with dexamethasone, and 3 (17%) of the 18 unoperated eyes had positive HSV-1 ocular cultures. Geographic ulcers appeared only in the PKP eyes treated with dexamethasone; 9 (82%) of the 11 PKP eyes treated with dexamethasone developed geographic ulcers. Between the 24th and 90th postoperative days, stromal keratitis appeared in 5 (56%) of the 9 PKP eyes treated with dexamethasone and in 2 (25%) of the 8 PKP eyes not treated with dexamethasone. Autograft PKP with postoperative corticosteroids significantly increased HSV-1 ocular shedding, epithelial ulceration, and stromal keratitis. This experimental model provides a useful tool to further investigate the development and treatment of HSV-1 epithelial and stromal recurrences after PKP.

An analysis of risk factor and survival in childhood acute lymphoblastic leukemia

To study the survival and prognostic factor of childhood acute lymphoblastic leukemia, 78 newly-diagnosed cases between January 1982 and June 1987 in National Taiwan University Hospital were reviewed and analyzed. They were stratified into two groups, i.e. standard-risk (SR) and high-risk (HR), according to their pre-treatment leukocyte count and age. Following induction therapy, 97% of the SR patients and 80% of the HR patients attained complete remission. In the SR group, the 2- and 3-year failure-free survival rates were 37% and 24%, with a median survival of 16 months. In the HR group, failure-free survival at the second and third year were 11% and 4%, respectively, with a median survival of 5.3 months. Three factors are strongly related to induction failure, i.e. high leukocyte counts (greater than 50*10(9)/1), massive hepatomegaly and large lymph nodes. Univariate analysis of failure-free survival showed six variables with significant detrimental effects on eventual outcomes, i.e. high leukocyte counts (greater than 50*10(9)/1), meningeal leukemia, marked lymphadenopathy, age younger than 2 years and older than 10 years, massive hepatomegaly (greater than 6 cm), and high LDH level (greater than 800 u/1). However, statistical survival models should also determine the joint effects of the prognostic factors so that the relative importance of each factor can be assessed. High initial leukocyte count, disclosed by multivariate analysis, was the single most important factor detrimental to the continuance of complete remission (P = 0.0004). Preliminary results also revealed poor compliance and early relapse in this study. Possible causes of early failure are discussed. Conceptual education for family members, as well as management with effective cytoreductive therapies are urgently needed.

Dyskeratosis congenita preceded by severe aplastic anemia: report of one case

Dyskeratosis congenita is a rare hereditary disease which usually manifests with skin hyperpigmentation, nail dystrophy, and leukoplakia of the mucous membrane (triad). This report describes a six-year-old boy with severe aplastic anemia who was later diagnosed to have dyskeratosis congenita. His unusual presentation was pancytopenia followed by leukoplakia of the tongue, hyperpigmentation of the skin and dystrophy of the nails. Treatment with horse anti-human lymphocyte immunoglobulin (ALG) for his aplastic anemia was not effective.

Extrahepatic biliary obstruction caused by cancer of non-liver origin in children: report of 5 cases

Obstructive jaundice secondary to external compression of the extrahepatic bile duct caused by tumor of non-liver origin was found in 5 of 199 consecutive children with cancer between 1986 and 1988 at the Department of Pediatrics, National Taiwan University Hospital. Of the 5 patients, 2 had non-Hodgkin's lymphoma and the other 3 had acute promyelocytic leukemia, histiocytosis X and neuroblastoma, respectively. Extrahepatic biliary obstruction occurred as part of the initial presentation of malignancy in 3 cases, and later in the course of disease in the other 2 cases. In each instance, abdominal ultrasonography and computed tomography revealed dilatation of intrahepatic biliary trees due to mass compressing effects. A huge multilobulated tumor and multiple enlarged lymph nodes near the porta hepatis were found in all 3 patients who underwent an exploratory laparotomy. Wedge biopsy of the liver showed no cancer cell invasion. One case died before chemotherapy had commenced. The other 4 patients received chemotherapy and 3 of them received additional radiotherapy. Although jaundice and tumor regressed dramatically with this mode of treatments, subsequent recurrence of tumor without jaundice rapidly ensued in 3 patients. They all died, except 1 case, within 18 months from the occurrence of jaundice. This suggests that these patients were in an advanced stage of disease and should be diagnosed early and treated vigorously. Accordingly, cancer of non-liver origin, although rare, should be considered in the differential diagnosis of obstructive jaundice if survival is to be improved in these cancer children.

Infection of human T-cell leukemia virus type I and development of human T-cell leukemia lymphoma in patients with hematologic neoplasms: a possible linkage to blood transfusion

Among 354 adult patients with either hematological malignancy or aplastic anemia, eight were positive for anti-HTLV-I antibodies; six of eight had received multiple transfusions. There was an approximately 3.5-fold increase (P less than .001) of HTLV-I seropositivity in the patients with hematologic disease (8 of 354, 2.23%) compared to the healthy adults older than 20 years (34 of 5252, .65%). Two hematological patients, one with Hodgkin's disease and one with acute promyelocytic leukemia, were found to be positive for HTLV-I, and developed and died of adult T-cell leukemia/lymphoma (ATL) subsequently. Both were long-term survivors of the primary disease and had received multiple transfusions. The latent period from blood transfusion to onset of ATL was 6 months and 11 years, respectively. Immunocompromised patients, who were seropositive for HTLV-I, may be at increased risk for ATL compared to healthy carriers of HTLV-I, and the latent period may be shorter.

Acute graft-versus-host disease: a clinical report and analysis of risk factors

Of the 31 cases of allogeneic bone marrow transplantation performed in the past 4 years at the National Taiwan University Hospital, 25 evaluable cases were retrospectively studied for incidence, severity, and risk factors of acute graft-versus-host disease (GVHD). The incidence was 60% (15/25) with the proportion of severe form (greater than or equal to grade II) being 53% (8/15). Skin involvement was the most common (13/15), gut the second (5/15), and liver the third (4/15). Most of the diagnosis of skin disease were confirmed by biopsy. Acute GVHD accounted for 3 deaths directly and was the next most common cause of death in post-transplant patients. The long-term survival rate for cases with grade 0-I disease was 65%, and that for those with grade II-III disease was 38%. Multivariate linear regression analysis of risk factors associated with severe form GVHD showed that the diagnosis of aplastic anemia was the most significant factor. Total lymphoid irradiation with or without plasmapheresis in aplastic anemia might contribute to the occurrence of severe acute GVHD.

Alloimmunization following blood transfusion

Although it has been 20 years since Rh immunoglobulin (Rhlg) was widely introduced in the United States, anti-D still remains as a frequent alloantibody found in hospital patients. Currently, anti-D is second in frequency only to anti-K as an alloantibody of clinical significance. Estimation of alloantibody frequencies in hospital patients reveals a gradual decline in the frequencies of anti-D and anti-CD, whereas anti-K, anti-E and anti-Jka show increases in relative and absolute frequencies. This phenomenon probably reflects the optimum use of Rhlg and more aggressive transfusion treatment of patients as indicated by the red cell use factor: (Red cell transfusions -- autologous transfusions)/admissions. Such a practice may be the result of the increasing severity of illness observed in patients admitted to hospitals. Alloimmunization due to donor white blood cells, platelets, and serum proteins also frequently follows the transfusion of homologous blood. These problems, which may pose additional risks to the transfusion recipient, are reviewed.

The current and future status of refractive surgery

Kerato-refractive surgery has developed rapidly over the past decade. Many surgical procedures have been described for the correction of myopia, hyperopia, and aphakia. For the treatment of myopia, radial keratotomy has been utilized extensively. Most investigators agree that radial keratotomy results seem to be better in patients with 3 diopters or less of myopia. Keratomileusis is a complicated procedure which can correct high degrees of myopia, however, this technically difficult procedure is performed by very few surgeons in North America. Epikeratophakia for the treatment of aphakia is promising especially in the treatment of pediatric patients. The Excimer laser is evolving from a research tool to clinical reality with the coupling of the laser to computer controlled programs to reshape the cornea. The use of synthetic material inlays and intrastromal corneal ring implants are also being developed to modify the refractive status of the cornea.

Bone marrow transplantation for severe aplastic anemia in children: conditioning with cyclophosphamide and total lymphoid irradiation

We used preparative regimens consisting of cyclophosphamide and total lymphoid irradiation in 4 children with severe aplastic anemia undergoing allogeneic bone marrow transplantation. All 4 children engrafted successfully in spite of the number of donors exposed in the previous blood components transfusion. Three of 4 transplanted children have survived for 390 days, 540 days, and 1,235 days respectively. One child died of graft-versus-host disease related sepsis. The actual survival rate was 75% at one year. Further efforts must be aimed at the elimination of graft-versus-host disease and the control of fatal infections.

Chromosome studies on 30 Chinese patients with acute nonlymphocytic leukemia in Taiwan

Cytogenetic studies were performed on 32 consecutive Chinese patients with de novo acute nonlymphocytic leukemia (ANLL) in Taiwan. Of the 30 patients with adequate specimens, 20(66%) had clonal chromosome abnormalities. Structural rearrangements were detected in 18 of them. Seven (four were children) of the 16 patients with M2 ANLL had t(8;21). All six patients with acute promyelocytic leukemia (APL; M3 subtype) had t(15;17). Two patients with M4 type leukemia and abnormal bone marrow eosinophils had inv(16)(p13q22). Another M4 patient with a mild increase of morphologically normal eosinophils in the bone marrow had an abnormal chromosome #16, t(1;16)(q21;p13) in which 16q22 was not involved. One patient with M5 ANLL had t(9;11). Only two patients had a numerical change as the sole abnormality. None of the patients had loss or deletion of chromosome #5 or loss of chromosome #7, and only one had a deletion of 7q. This study revealed a high incidence of t(8;21), t(15;17), and a low incidence of -5/5q- or -7/7q- in Chinese patients with ANLL.

Ultrasonography of pathologically proved choroidal melanoma with a high-resolution small-parts scanner

Between March 1983 and March 1985, 13 patients with choroidal melanoma underwent ultrasonography with a high-resolution small-parts scanner. The patients subsequently underwent enucleation, and the specimens were examined histopathologically. We reviewed the ultrasonograms for the presence of choroidal excavation, rupture through Bruch's membrane, retro-orbital fat shadowing, acoustic texture and retinal detachment. Comparison with the histopathological results showed that when conventional diagnostic criteria were used, most cases of rupture through Bruch's membrane were missed owing to the limits of resolution. No patients with homogeneous acoustic texture had pathological evidence of tumour necrosis or hemorrhage, while most of those with inhomogeneous texture did. The results suggest that high-resolution small-parts scanning may lead to reassessment of the conventional criteria for the diagnosis of intraocular melanomas.

Long interspersed repeated DNA (LINE) causes polymorphism at the rat insulin 1 locus

The insulin 1, but not the insulin 2, locus is polymorphic (i.e., exhibits allelic variation) in rats. Restriction enzyme analysis and hybridization studies showed that the polymorphic region is 2.2 kilobases upstream of the insulin 1 coding region and is due to the presence or absence of an approximately 2.7-kilobase repeated DNA element. DNA sequence determination showed that this DNA element is a member of a long interspersed repeated DNA family (LINE) that is highly repeated (greater than 50,000 copies) and highly transcribed in the rat. Although the presence or absence of LINE sequences at the insulin 1 locus occurs in both the homozygous and heterozygous states, LINE-containing insulin 1 alleles are more prevalent in the rat population than are alleles without LINEs. Restriction enzyme analysis of the LINE-containing alleles indicated that at least two versions of the LINE sequence may be present at the insulin 1 locus in different rats. Either repeated transposition of LINE sequences or gene conversion between the resident insulin 1 LINE and other sequences in the genome are possible explanations for this.

Fatal primary Epstein-Barr virus infection masquerading as histiocytic medullary reticulosis in young children in Taiwan

We reported 3 fatal cases of primary Epstein-Barr virus (EBV) infection resembling histiocytic medullary reticulosis (HMR) in young children in Taiwan, where an HMR-like illness has been previously found to be prevalent. The disease ran a fulminant course, manifesting as fever, anemia, jaundice, skin rash, pulmonary infiltration, and/or hepatosplenomegaly lasting for only 1-3 weeks. Laboratory tests revealed no hemolytic anemia and Coombs test was negative. Sepsis or HMR was the main clinical differential. At autopsy, the spleen, liver, lymph node, lung, and bone marrow showed infiltration of atypical "histiocytes" or blasts, lymphocytes, and mature histiocytes with hemophagocytosis. Immunophenotype and gene rearrangement studies of the lymphoid tissues revealed that these atypical "histiocytes" were actually polyclonal B immunoblasts in one case and transformed T lymphocytes in the remaining 2 cases, representing two different types of virus-host interaction. Southern blot and in situ hybridization studies on frozen lymphoid tissues demonstrated the presence of EBV DNA in all 3 patients; the study for cytomegalovirus was negative. The young age of these patients, closely correlated with the prevalent age of primary EBV infection in the general populations in Taiwan, strongly suggest that these childhood cases of previously diagnosed HMR-like disease may actually represent a lethal form of primary EBV infection or fatal infectious mononucleosis.