Is Mycoplasma Pneumonia associated with childhood acute lymphoblastic leukemia?

Acute lymphoblastic leukemia (ALL) in the childhood peak may be a rare response to delayed first exposure to one or more common infectious agent(s). Mycoplasma Pneumonia has the appropriate socioeconomic correlates and clinical symptoms and the hypothesis that delayed first exposure to it may contribute to ALL is considered. Counts of positive reports of M Pneumonia from disease surveillance data for England and Wales (United Kindom) for 1975-92 have been taken as proxies for community burden of infection. Variation by months of birth (cohort) and diagnosis (period) of incidence of ALL in children born and diagnosed 1975-92 are compared with predictions. When periods were classified by mean M Pneumonia count rate in the nine preceding months, standardized morbidity ratios (SMR) for the highest and lowest 20 percent were 108 and 89 (rate ratio [RR] = 1.2, 95 percent confidence interval [CI] = 1.1-1.4). SMRs for cohorts with highest and lowest predicted risk (i.e., lowest and highest M Pneumonia count rate around birth and during infancy) were 110 and 97 (RR = 1.1, CI = 1.0-1.3). The trend for period was most marked in the cohorts with low opportunity for exposure when young. This ecologic analysis provides preliminary support for the hypothesis.

[Erysipelothrix rhusiopathiae bacteremia in a child with acute leukemia]

The systemic infections caused by E. rhusiopathiae and reported in literature are very rare, majority evolving with endocarditis. The authors present a child with acute leukemia, to whom the blood culture during a high temperature episode allows to isolate this bacterium, without valvular lesions. The case is interesting because of the arisen bacteriological diagnosis problems and because of the pathogenic aspects of the infection. An animal source contact being absent, we took in account the intestinal carriage which, under the profound depression of the defence (the underlaying disease and the cytostatic therapy) could result in a persistent bacteremia. The treatment with cefazolin allows the infection to be cured.

[Edwardsellia tarda septicemia in chronic lymphoid leukemia]

Edwardsiella tarda is a Gram negative bacilli. At least 300 cases have been reported in the literature. Here we report a new case of Edwardsiella tarda septicemia in an immunocompromised patient with chronic lymphocytic leukemia. Chief infections associated with this bacterium include bacterial gastroenteritis and septicemia with fatal evolution in 50% of cases. Risk factors associated with Edwardsiella tarda infections include exposure to aquatic environments and exotic animals. Although studies indicate that this bacterium is susceptible to most commonly prescribed antibiotics, it is interesting to note that in our case, Edwardsiella tarda was resistant to numerous beta-lactamins.

[Some factors influencing the number of staphylococci in the mouth and throat of children]

The relationship between the count of polymorphonuclear granulocytes in blood and also between the percentage of oral and pharyngeal streptococci showing antagonistic activity on the indicator strain Staphylococcus aureus 209P and the number of staphylococci in the oral cavity and pharynx were investigated. The study comprised 92 children, of both sexes, aged 4-15; among them there were 48 children with the decreased number of circulating polymorphonuclear granulocytes due to the treatment of acute lymphoblastic leukaemia (ALL). A statistically significant negative correlation between the number of polymorphonuclear granulocytes in blood and the count of oral and pharyngeal staphylococci (both coagulase-negative and coagulase-positive) in children with ALL as well as in healthy children was revealed. The Pearsons linear correlation coefficients between these parameters were r = -0.364 (p < 0.001) and r = -0.313 (p = 0.019) for the oral cavity and for the pharynx, respectively. The streptococci showing antagonistic activity had only some influence on the count of staphylococci in the oral cavity. The Pearson's linear correlation coefficient between this number and the count of staphylococci in 1 ml of saliva was r = -0.382 (p < 0.001).

[Gas gangrene as a manifestation of endogenous Clostridium septicum infection]

Endogenous, nontraumatic clostridial myonecrosis has a frequent association with colon carcinoma, leukemia, diabetes mellitus, and drug-induced immunosuppression. We present two cases of Clostridium septicum myonecrosis. An 18-year-old girl developed severe abdominal pain on day 7 after hospitalization for cytostatic treatment of acute lymphoblastic leukemia. Blood cultures yielded Clostridium septicum and histopathological exam of muscle tissue showed extended myonecrosis. Eventually the patient recovered with antibiotics and surgical therapy. A 72-year-old diabetic woman was treated as an outpatient with an intramuscular injection of steroidal antiphlogistics for "acute lumbar disc disease". The next morning persistence of hip pain and discoloration of the right thigh caused hospitalization under the suspected diagnosis "fracture of the neck of the femur". Clostridium septicum was cultured from intraoperatively taken swabs. At autopsy, in addition to the gangrene, there was an adenocarcinoma of the cecum, which had not been diagnosed during life.

Immunoblastic transformation of a Sezary syndrome in a black Caribbean patient without evidence of HTLV-I

We describe an unusual case of Sezary syndrome which transformed into a large T-cell non Hodgkin's lymphoma (immunoblastic) in a black man of Caribbean descent with negative HTLV-I serology and no evidence of HTLV-I infection by DNA analysis using sensitive techniques. The disease presented as a small-cell Sezary syndrome and transformed in an inguinal lymph node one year from diagnosis. Immunological markers in the small and large cells showed a mature T-cell phenotype CD4+, CD8- with expression of T-cell activation markers and a high proliferative rate. Ultrastructural analysis confirmed small Sezary cells with serpentine nucleus in the peripheral blood and immunoblasts in the lymph node. Cytogenetics demonstrated complex clonal chromosome abnormalities with involvement of 7q35, the locus for the beta chain of the T-cell receptor (TCR). Southern-blot analysis showed the same rearrangement of the TCR beta, gamma, delta chain genes in lymph node and peripheral blood cells. Antibodies to HTLV-I were not detected in the serum by ELISA and particle agglutination (PA) nor HTLV-I specific sequences were demonstrated by nested polymerase chain reaction with primers to the envelope proteins, LTR and tax/rex of HTLV-I in both tissues, blood and lymph node. The disease had an aggressive course and was refractory to therapy; the patient died of progressive disease 28 months from presentation. Two unusual features characterised this patient's illness: immunoblastic transformation of a Sezary syndrome in a patient of Afro-Caribbean origin without evidence of HTLV-I DNA sequences and negative HTLV-I serology and the atypical lymph node histology resembling ATLL.

Ten-year survey of incidence of infection as a cause of death in hematologic malignancies: study of 90 autopsied cases

We investigated 90 autopsied cases with hematologic malignancy, including malignant lymphoma (ML), acute leukemia (AL), and adult T-cell leukemia (ATL) peculiar to our district, during the 10-year period 1982-1991 to determine the change in incidence of infection as a cause of death. We divided the cases into two groups representing the first half decade (1982-1986) and the second half decade (1987-1991) and compared the findings made in the two groups. Although infection was the major cause of death in those autopsied cases, the incidence of fatal infections decreased during the latter period. The incidence of fatal bacterial infections decreased, while fungal infections showed a relative increase. Pneumocystis carinii pneumonia and cytomegalovirus (CMV) infection occurred more frequently in patients with ATL than in those with ML or AL. Combined infection by more than three pathogens was observed in 2 cases of ATL. Our study revealed the characteristics of ATL specific to our district, and indicated the need to apply new strategies to prevent and treat fungal and viral infections in patients with hematologic malignancies.

Impaired antibody levels to tetanus toxoid and pneumococcal polysaccharides in acute leukemias

Antibody levels to the protein antigen tetanus toxoid (TTx) and the carbohydrate antigens pneumococcal capsular polysaccharides (PCP) were studied by enzyme immunoassay in 14 patients with acute lymphocytic leukemia (ALL) and 32 patients with acute non lymphocytic leukemia (ANLL) before and three weeks after initiation of chemotherapy. The antibody levels to TTx were significantly lower in ALL patients than in controls. This was associated with elevated levels of sCD8 (soluble CD8) in the serum of 12 out of the 14 ALL patients. Patients with ANLL had normal antibody levels before chemotherapy. After chemotherapy ANLL patients with septic complications had a reduced increase of antibody titers to TTx than patients without sepsis. The average antibody titers to PCP decreased in patients with sepsis, while they increased slightly in patients without sepsis. We conclude that in contrast to ANLL patients ALL patients have preexisting decreased antibody levels to thymus dependent protein antigens, while antibody levels to thymus independent carbohydrate antigens are normal in both types of leukemias.

Impaired cell-mediated immunity to cytomegalovirus (CMV) in leukemic children with prolonged CMV viruria

To determine the role of cell-mediated immunity (CMI) to cytomegalovirus (CMV) in leukemic children after CMV infection, CMI to CMV antigen was studied using CMV-specific lymphocyte blastogenic responses (LBR) and interferon (IFN) production. Four children, who continuously secreted CMV in urine more than 2 years after symptomatic CMV infection (CMV disease) (group 1), showed impaired LBR to CMV antigen, though they had normal LBR to phytohemagglutinin (PHA) and concanavalin A (Con A). Impairment of LBR either to AD-169 strains or autologous and heterologous wild strains was observed. IFN production was not detected in three of four children. Six leukemic children, who had no viruria after cessation of CMV disease (group 2), showed good responses to CMV antigens. IFN was detected in all six children in group 2. Eight leukemic children, who were seropositive to CMV at the onset of leukemia (group 3), showed good responses to CMV antigens and IFN production. These results suggest that impaired cell-mediated immunity to CMV antigen might contribute to prolonged excretion of CMV in urine in leukemic children.

Characterization of Marek's disease virus BamHI-A-specific cDNA clones obtained from a Marek's disease lymphoblastoid cell line

A cDNA library was constructed from poly(A)+ RNA fractions obtained from a Marek's disease (MD) lymphoblastoid cell line, MDCC-CU41, in which viral gene expression is very limited. Three independent groups (1, 2, and 3) of MD virus (MDV)-specific clones were obtained, which were mapped in the inverted repeat region of the BamHI-A fragment of the MDV genome. Northern blot analysis showed that probes prepared from these cDNA clones hybridized with several transcripts of different sizes in poly(A)+ RNA of MDCC-CU41, although the amounts of these transcripts were relatively small compared to those in MDV lytically infected cells. Moreover, a small open reading frame, which can encode a 94-amino-acid protein, was identified in the A41 cDNA clone (Group 3). By RNase protection assays, the 1.2-kb Group 3 transcriptional unit has been defined. In indirect immunofluorescent antibody assays, antiserum against the bacterially expressed fusion protein, glutathione S-transferase-A41, reacted specifically with the cytoplasmic regions of MDV (strain RB1B)-infected chick kidney cells. However, MDCC-CU41 did not contain a detectable level of the protein determined by these methods.

Osteomyelitis and intervertebral discitis caused by Blastoschizomyces capitatus in a patient with acute leukemia

We describe the first known case of vertebral osteomyelitis and discitis caused by Blastoschizomyces capitatus in a leukemic patient and the results of therapy. We also reconfirm the microbiological characteristics which differentiate this species from other yeastlike pathogens.

Study on cytomegaloviral infection in acute leukemia patients by polymerase chain reaction

Polymerase chain reaction (PCR) and blot hybridization by probe labelled with digoxin were used to detect human cytomegalovirus (HCMV) DNA in 31 patients with acute leukemia and 20 controls. The positive rate detected by PCR in acute leukemia was 74.2% and 15.0% in the controls. The difference was statistically significant. The results suggest that acute leukemia patients are the high risk population with high infection rate of HCMV. The positive rate detected by digoxin method in acute leukemia was 58.1%. Six patients showed negative results by digoxin method, but positive by PCR. It was demonstrated that PCR was superior to digoxin method in sensitivity. Anti-HCMV IgM in serum of patients was detected at the same time, the positive rate was 16.1%. Only 6 of the 23 PCR positive patients showed positive anti-HCMV IgM. It suggests that the immune response is weak in acute leukemia patients and HCMV recently infected could not be excluded in the anti-HCMV IgM negative cases.

Surveillance and management of infection in a haematology unit: use of an in-house clinical database

An effective infection control surveillance programme is essential for the management of patients in a haematology unit. The programme can contribute to the production of antibiotic policies, the monitoring of current clinical practice and has potential in the cost analysis of infection. The use of a computerized database facilitates the management of such a programme. We describe an infection control database using dBASE IV software which runs on a personal computer. The system can accept data sets from other relevant databases and allows the generation of infection control data appropriate to the unit.

Establishment of human T-cell leukemia virus type I T-cell lymphomas in severe combined immunodeficient mice

Human T-cell leukemia virus type I (HTLV-I) is recognized as the etiologic agent of adult T-cell leukemia (ATL), a disease endemic in certain regions of southeastern Japan, Africa, and the Caribbean basin. Although HTLV-I can immortalize T lymphocytes in culture, factors leading to tumor progression after HTLV-I infection remain elusive. Previous attempts to propagate the ATL tumor cells in animals have been unsuccessful. Severe combined immunodeficient (SCID) mice have previously been used to support the survival of human lymphoid cell populations when inoculated with human peripheral blood lymphocytes (PBL). SCID mice were injected intraperitoneally with PBL from patients diagnosed with ATL, HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP), or from asymptomatic HTLV-I-seropositive patients. Many of these mice become persistently infected with HTLV-I. Furthermore, after human reconstitution was established in these mice, HTLV-I-infected cells displayed a proliferative advantage over uninfected human cells. Lymphoblastic lymphomas of human origin developed in animals injected with PBL from two ATL patients. The tumor cells represented outgrowth of the original ATL leukemic clone in that they had monoclonal or oligoclonal integrations of the HTLV-I provirus identical to the leukemic clone and predominantly expressed the cell surface markers, CD4 and CD25. In contrast, cell lines derived by HTLV immortalization of T cells in vitro did not persist or form tumors when inoculated into SCID mice, indicating differences between in vitro immortalized cells and ATL leukemic cells. This system represents the first small animal model to study HTLV-I tumorigenesis in vivo.

Evidence for the role of CR1 (CD35), in addition to CR2 (CD21), in facilitating infection of human T cells with opsonized HIV

Complement activation by HIV results in the binding of C3 fragments to the gp160 complex and enhanced infection of C3 receptor-bearing target cells. We have studied complement-mediated enhancement of infection of the human CD4-positive T-cell line HPB-ALL which expresses the CR1 (CD35) and CR2 (CD21) receptors for C3. CR1 and CR2 are present on 15% and 40% of normal peripheral blood CD4-positive T lymphocytes respectively. Opsonization of the virus with complement resulted in a 3- to 10-fold enhancement of infection of HPB-ALL cells, as assessed by measuring the release of p24 antigen in culture supernatants throughout the culture period. Blockade of CR2 with cross-linked anti-CR2 monoclonal antibodies decreased infection to the level observed with unopsonized virus. Blocking CR1 reduced complement-mediated infection by 50-80%. Experiments using serum deficient in complement factor I demonstrated that CR1 mediates the interaction between opsonized virus and T cells in addition to its ability to serve as a cofactor for the cleavage of C3b into smaller fragments that interact with CR2. A requirement for CD4 in complement-mediated enhancement of infection was observed with HIV-1 Bru but not with HIV-1 RF. Thus, CR1 and CR2 contribute in an independent and complementary fashion to penetration of opsonized virus into complement receptor-expressing T cells. Involvement of CD4 in infection with opsonized virus depends on the viral strain.

Changes in the oral microflora during cytotoxic chemotherapy in children being treated for acute leukemia

Thirty-four children with diagnosed cases of acute leukemias and being treated with cytotoxic chemotherapy at St James' Hospital, Leeds, were followed for between 6 months and 1 year to determine the changes in their oral microflora. They were examined before treatment commenced and then at monthly intervals. Swabs were taken from the oral cavity to test for the presence or absence of bacteria and Candida. Saliva samples were also used to assess the levels of Streptococcus mutans in the mouth. Sensitivity tests were carried out to assess the effect of the cytotoxic agents on the oral flora. All children received prophylactic nystatin and chlorhexidine gluconate mouthrinses four times daily for the whole period of the study. There was significant difference (p < 0.0001) for counts of S. mutans at different treatment stages. Sensitivity tests showed that S. mutans was sensitive to the cytotoxic drug daunorubicin, and this drug was probably responsible for the fall in S. mutans counts. A significant difference was also found in the types of bacteria isolated between the study and reference groups, but there was no change in the composition of the flora in the study group during treatment. These bacteria were also found to mirror those cultured from routine blood samples in children with acute leukemia.

An infectious etiology for common acute lymphoblastic leukemia in childhood?

Childhood leukemia is a biologically and clinically diverse disease and is likely to arise via a number of etiological pathways. The common, B-cell precursor, form of acute lymphoblastic leukemia (cALL) accounts for the peak of childhood leukemia at 2-5 years of age. Recent epidemiological data, reviewed here, indicate that risk of cALL is increased by higher socio-economic status, isolation, and other community characteristics suggestive of abnormal patterns of infection during infancy. These data are compatible with the emerging concept that cALL may be a rare response to common infection(s).

[Quantitative changes of bacterial flora from the oral cavity and throat in children with acute lymphoblastic leukemia]

Quantitative investigations were carried on aerobic and anaerobic bacterial flora of oral cavity and throat in 44 children in the age of 5-10 years with acute lymphoblastic leukemia, intensively treated with cytostatics, and in 23 healthy children which served as a control group. Samples of saliva from leukemic children revealed significantly higher than in control group--presence of aerobic bacteria, particularly streptococci and enterococci. Material from throat was differing only in regard to staphylococci. Moreover, in children with leukemia, Gram-negative rods were present, which was not the case in the control group.

Gram-negative enteric bacteria in the oral cavity of leukemia patients

We examined changes in the bacterial flora in hospitalized patients with leukemia. This study placed special emphasis on enteric microorganisms and their relation to the general status of the patient. One hundred thirty bacterial cultures from 16 leukemia patients and 16 control subjects, were obtained. The organisms were isolated on MacConkey agar and identified by the API-20E system. Enteric microorganisms were isolated from 62.2% of the leukemia patients as compared with 28% from the control group (p < 0.001). The enteric positive cultures were identified as Klebsiella (42.7%), Enterobacter (18.8%), and Pseudomonas (15.6%). In contrast to the negative cultures (1342), enteric microorganisms were cultured from 2948 specimens (p < 0.005).

Selective oral antimicrobial prophylaxis for the prevention of infection in acute leukaemia-ciprofloxacin versus co-trimoxazole plus colistin. The EORTC-Gnotobiotic Project Group

230 leukaemic patients were entered into a randomised, prospective, multicentre trial of either ciprofloxacin (1 g/day) or co-trimoxazole (1920 mg/day) plus colistin (800 mg/day) for the prevention of infection during granulocytopenia. Bacteraemia due to resistant gram-negative rods occurred only in the co-trimoxazole-colistin group though both regimens were effective for selective gastrointestinal tract decontamination. However, there were fewer patients without any infective complications (31% vs. 18%: P = 0.02), fewer febrile days [mean (S.D.) 5.9 (1.1) vs. 8.2 (1.4): P = 0.0242], a lower proportion of infective events (0.9 (0.16) vs. 1.2 (0.18): P = 0.005) and fever occurred later (median 19 vs. 14 days: 0.025 less than P less than 0.05) in the co-trimoxazole-colistin group. The choice of prophylactic regimen therefore appears to depend upon whether or not protection against gram-negative infection is required or better systemic prophylaxis overall.

Cutaneous Fusarium infection in an adolescent with acute leukemia

Disseminated fusariosis occurred in a pediatric patient with acute lymphocytic leukemia in relapse. The patient had fever and neutropenia, and scattered violaceous papules and vesicles with central erosions that rapidly progressed to generalized, painful, violaceous, papulovesicular lesions with central necrosis. Severe myalgias were associated. The diagnosis was suspected by noting hyphae on a smear of vesicular contents, and confirmed by culture. The clinical course was rapidly fatal despite early institution of amphotericin B therapy. Disseminated Fusarium infection should be suspected in immunocompromised patients with fever and neutropenia who have generalized, eroded, violaceous papules, vesicles, and pustules, particularly with associated myalgias.