Spontaneous resolution of primary erythrocytosis in two girls

We report two girls with primary erythrocytosis in whom extensive diagnostic studies revealed no underlying cause. Normal growth of colonies derived from erythroid burst forming units (BFU-E) was observed, and serum erythropoietin concentrations were within or below the normal range. The absence of a rise in serum erythropoietin levels after isovolemic phlebotomy implicated the erythroid marrow as the site of the pathophysiologic abnormality in both patients. Spontaneous resolution of erythrocytosis occurred during the second decade of life. Our experience suggests that primary erythrocytosis may be self-limited in some children. In these cases, the proliferative abnormality may be sufficiently subtle as to not be detected by standard in vitro culture systems, which support the growth of colonies derived from erythroid progenitors.

Rejection of bone marrow transplant and resistance of alloantigen reactive cells to in vivo deoxyadenosine in adenosine deaminase deficiency

Severe combined immunodeficiency disease (SCID) in patients with adenosine deaminase (ADA) deficiency is thought to result from increased levels of purine metabolites. We attempted to immunosuppress a patient with ADA deficiency and SCID using a continuous infusion of deoxyadenosine to obtain engraftment of a T cell-depleted haplocompatible parental bone marrow graft. Before administering the drug in vivo, we investigated hematopoietic colony formation in two children with ADA deficiency (including the potential recipient), the obligate heterozygote donor (father), and normal controls using deoxyadenosine and erythro-9-(2-hydroxy-3-nanyl)adenosine (EHNA), and inhibitor of ADA. Deoxyadenosine alone in concentrations as high as 100 microM had no significant affect on erythroid (BFU-E) or myeloid (CFU-c) colony formation. However, in the presence of EHNA there was a significant reduction in BFU-E and CFU-c growth in all subjects and controls. Increasing doses of deoxyadenosine were given to one patient with ADA deficiency and SCID as a continuous 24-hr intravenous infusion. We found that there was a linear relationship between the dose administered and the plasma level; however, doses greater than 100 mg/day were required to increase erythrocyte dATP levels. We were able to raise intracellular dATP levels to more than three times baseline with doses of deoxyadenosine of 200 mg/day. However, there were no significant effects on the absolute lymphocyte counts or the lymphocyte responses to mitogen or alloantigen, and the haploidentical marrow failed to engraft. Our results suggest that the bone marrow of ADA-deficient patients is normal with respect to standard colony formation, that inhibitors of ADA do not adequately model the deficient state, and that the immunodeficiency in ADA deficiency is not proportionately related to either the deoxyadenosine or dATP levels, both of which were significantly elevated at the time of transplantation.

Controlled-release carbidopa/levodopa (CR4-Sinemet) in Parkinson's disease patients with and without motor fluctuations

Sixteen patients with advanced Parkinson's disease (PD) and motor fluctuations were evaluated throughout 12 months of open label therapy on CR4-Sinemet. Reduced dosage frequency and significant motor improvement with reduced fluctuation occurred and were maintained with CR4-Sinemet compared with baseline on Sinemet. In a double-blind protocol using CR4-Sinemet in 20 stable PD patients, CR4-Sinemet was given twice daily and compared with Sinemet given four times daily. Patients remained stable without improvement or deterioration when the long-acting drug was substituted at 50% frequency. Plasma levodopa levels with CR4-Sinemet were smoother than with Sinemet. Although some patients receiving CR4-Sinemet found they functioned more slowly in the morning, the easier dosing schedule and improved amount of "on" time in fluctuators suggest that this formulation may become increasingly useful in managing PD.

The adrenal medullary transplant operation for Parkinson's disease: clinical observations in five patients

The recent report by Madrazo and coworkers on the successful treatment of Parkinson's disease using adrenal medullary tissue transplanted to the caudate nucleus has aroused international interest in the procedure. The present article reports our initial experiences with the operation in five patients and discusses the postoperative effects of the procedure, the protocol used to monitor motor performance, and the need for cooperation with the two registries that have been created to follow morbidity, mortality, and efficacy. We intend to alert the neurosurgeon to important side effects, but not to assess the long term efficacy of the procedure. Postoperatively, a number of transient effects were seen in our patients, the most striking being somnolence, delusions, and lack of significant pain in spite of a large abdominal incision. The only complications have been respiratory. After the early postoperative period, gradual improvement of on-off times and Schwab-England disability scores was seen over 20 weeks. Long term cooperative studies are needed to demonstrate the efficacy of this procedure. neurosurgeons doing transplant operations are urged to join the registries so that uniform information can be collected.

Amantadine and motor fluctuations in chronic Parkinson's disease

Twenty patients with idiopathic Parkinson's disease (PD) and motor fluctuations received open-label amantadine (100-200 mg/d) in addition to their other antiparkinson medications. One patient had unpredictable motor fluctuations (on-off) and the others had end-of-dose wearing-off. The effect of amantadine on motor fluctuations and parkinsonian disability was tested at 1, 2, and 3 months. Moderate improvement in motor fluctuations occurred in 55% of the patients at 2 months and 65% of patients at 3 months of treatment (p less than 0.01). There was also significant improvement in parkinsonian disability. The duration of improvement averaged 5.7 months, and all patients deteriorated to their baseline level of function within 12 months. This study suggests that the addition of amantadine can transiently improve motor fluctuations and have a significant impact on overall disability in patients with chronic PD.

Circulating erythroid progenitors in the anemia of prematurity

We studied erythropoiesis in infants with the anemia of prematurity by counting the number of colonies derived from erythroid burst-forming units (BFU-E) in the blood of 11 premature infants before they received transfusions. Colony growth in blood from the infants was compared with growth in blood from adults and umbilical-cord blood from term infants, in the presence of erythropoietin, 0 to 2000 mU per milliliter. Addition of increasing concentrations of erythropoietin resulted in a stepwise increase in the number of colonies derived from BFU-E (P less than 0.0005) of all three groups of subjects. Cultures stimulated with 2000 mU of erythropoietin yielded 28.1 +/- 7.6, 88.0 +/- 19.4, and 121.0 +/- 22.5 bursts (mean +/- SE) per 10(5) cells plated in blood from adults, blood from premature infants, and cord blood, respectively. Although more BFU-E-derived colonies appeared when 200 or 2000 mU were present per milliliter in cultures of the infants' blood and cord blood, the intrinsic responsiveness of BFU-E to erythropoietin was similar in all groups. Although the mean hematocrit was 26 percent, mean serum erythropoietin concentrations (+/- SD) in the infants (20.7 +/- 10.0 mU per milliliter) were not significantly different from those in the adult controls (24.0 +/- 6.5). We conclude that progenitor cells committed to erythroid differentiation are present during the anemia of prematurity, and that the intrinsic responsiveness of the circulating BFU-E pool to erythropoietin is normal. These results implicate inadequate production of erythropoietin as the cause of the anemia of prematurity and suggest that recombinant erythropoietin might provide a therapeutic alternative to transfusion for symptomatic babies with this condition.

A rating scale for Gilles de la Tourette's syndrome: description, reliability, and validity data

We developed a rating scale for tic disorders that uses only objective criteria and accommodates the variety of tic manifestations. Using short videotaped recordings with the examiner out of the taping room, we measured five tic variables: number of body areas affected, frequency of motor tics and vocalizations, and severity of motor tics and vocalizations. The rating scale fulfilled tests for inter-rater reliability and temporal stability, and correlated well with scales used to assess global changes over prolonged periods. It objectively detected improvement in tics with neuroleptics, the one pharmacotherapy accepted to abate tics in most patients.

Parkinson's disease and motor fluctuations: long-acting carbidopa/levodopa (CR-4-Sinemet)

Long-acting levodopa/carbidopa combination (CR-4-Sinemet) was compared with traditional levodopa/carbidopa (Sinemet) open label in 20 patients with Parkinson's disease and "wearing-off" phenomena. After 4 to 6 weeks of therapy with CR-4-Sinemet, the number of daily doses of medication dropped significantly compared with traditional Sinemet, disability improved, and "on" time increased. In nine patients receiving CR-4-Sinemet for 3 months, the number of daily doses and the on time without chorea remained significantly improved. CR-4-Sinemet peaked in plasma after 2 hours, and moderately high levels remained at 4 hours after the dose. Side effects were similar between traditional Sinemet and CR-4 Sinemet.

Progression of Parkinson's disease without levodopa

We studied 100 consecutive patients with Parkinson's disease (PD) who were not receiving levodopa and followed them until symptoms advanced and levodopa was given. Eighty-three patients eventually received levodopa; 50% started within 36 months after a mean duration of symptoms of 48 months. Patients starting on levodopa showed significant progression of their disease compared with their baseline examination. These data have direct applicability to the design and implementation of future protocols aimed at preventing disease progression of PD.

Clonidine and Gilles de la Tourette's syndrome: double-blind study using objective rating methods

Clonidine has been suggested to be effective in Gilles de la Tourette's syndrome (GTS), but no double-blind study has ever evaluated its effects using objective measures. Thirty patients with GTS completed a 6-month placebo-controlled crossover study of the effectiveness of clonidine. Videotapes were obtained at each 3-week visit and were evaluated randomly at the end of the study for distribution, frequency, and severity of motor and vocal tics. Quantifiable psychometric examinations were performed as well. The use of clonidine did not significantly (p less than 0.05) reduce motor tics, vocalizations, or behavior. The effect of a low dose (0.0075 mg/kg/day) was no different from that of a high dose (0.015 mg/kg/day); children's responses were no different from adults'; and those also receiving neuroleptic agents showed the same lack of efficacy as seen in patients on no other medication. Dosing schedule did not affect the objective ratings; scores from clonidine given twice a day were equivalent to those for three times a day.

Juvenile monosomy 7 syndrome: evidence that the disease originates in a pluripotent hemopoietic stem cell

The present study was undertaken to investigate the hemopoietic cell from which malignant change evolves in juvenile dyshemopoiesis with monosomy 7. Two male patients, aged 18 and 5 months, were studied using progenitor assays combined with cytogenetics. Both had hepatosplenomegaly, cytopenias and a cellular marrow. The karyotype in direct marrow was 45,XY-7/47,XY,+8/46,XY in patient 1 and 45,XY,-7/46,XY in patient 2. Patient 1 received chemotherapy but developed acute nonlymphocytic leukemia after 17 months and died 20 months after diagnosis. During this time marrow metaphases with 45,XY,-7 increased to 100% (25/25). Patient 2 received an allogeneic marrow transplant 4 months after diagnosis which did not engraft. In both patients progenitors of both small (CFU-E) and large (BFU-E) erythroid colonies were present at normal frequencies. However, the colonies produced were small and poorly hemoglobinized with some erythropoietin-independent maturation. Progenitors of large granulocyte/macrophage colonies (CFU-GM) were present at an elevated frequency in the marrow of patient 1 and in the blood all progenitor classes were markedly increased. Cytogenetic analysis of colonies from this patient showed BFU-E to be 45,XY,-7 or 47,XY,+8 and CFU-GM to be 45,XY,-7 or 47,XY,+8 or 46,XY. In patient 2, most BFU-E were 45,XY,-7, although a few were 46,XY. These data indicate that malignant change in this disease involves hemopoietic stem cells capable of erythroid and in at least some cases, myeloid differentiation.

The autonomic nervous system in Gilles de la Tourette's syndrome

Twenty-three patients with Gilles de la Tourette's syndrome (GTS) underwent noninvasive investigation of autonomic nervous system (ANS) function, as did 23 age-matched controls. ANS function in GTS patients was no different from that of controls, and patients receiving neuroleptic drugs had the same ANS function as untreated patients. All 23 patients later received clonidine and were retested. The ANS values before administration of clonidine were compared with those while patients were taking clonidine. The only significant change (p less than 0.01) with clonidine was a reduced resting pulse rate. The combination of clonidine and neuroleptic drugs did not induce significant autonomic changes compared with neuroleptic therapy alone. These results indicate that the ANS in GTS patients is normal and that the drugs used to abate tics do not produce clinically significant changes in ANS when chronically given. The findings suggest that the pathophysiology and treatment of GTS do not directly involve the nuclei or tracts of autonomic regulation.

Selective inhibition of the growth of human erythroid bursts by monoclonal antibodies against transferrin or the transferrin receptor

The relative requirements of colonies derived from erythroid (BFU-E) and myeloid (CFU-c) progenitors for transferrin were examined using monoclonal antibodies directed against the transferrin molecule (TF-6) or its cell surface receptor (TFR-A12, TFR1-2B). Growth of erythroid bursts was profoundly reduced at concentrations of all three antibodies that had no effect on CFU-c-derived colonies. When TFR1-2B was layered over cultures established one to seven days previously, further burst development was inhibited, and degeneration of early erythroid colonies was observed. Addition of erythropoietin augmented transferrin receptor expression on cells harvested after 1 to 2 weeks in culture and analyzed by flow cytometry. Recombinant human erythropoietin gave results comparable to those obtained in experiments using human urinary erythropoietin. Analysis of erythroblasts plucked directly from culture plates confirmed the presence of transferrin receptors on BFU-E-derived colonies. Thymidine incorporation was maximal early in the second week of culture and coincided with high transferrin receptor expression. These data demonstrate that transferrin must be available into the second week of culture to support the growth and differentiation of BFU-E-derived erythroid bursts, that the generation of erythroid colonies from BFU-E is more dependent on transferrin than myeloid colony formation from CFU-c, and that erythropoietin modulates the expression of transferrin receptors on growing bursts.

Acquired immune deficiency syndrome in childhood

The acquired immunodeficiency syndrome has been observed with increasing frequency in children with associated hemophilia, high-risk environmental backgrounds, and blood transfusions. AIDS should be considered in the differential diagnosis of childhood immunodeficiency, and it must be distinguished from congenital disorders. We emphasize the importance of epidemiologic, clinical, and laboratory data in diagnosis and aggressive management of infectious complications. The relationship between human retrovirus infection and AIDS remains to be precisely defined, especially with regard to cofactors that may play a role in the development of severe immunodeficiency following exposure to the agent.

Disordered swallowing due to a syrinx: correction by shunting

Disturbed deglutition is common in diseases of the brainstem and lower cranial nerves, but little is known about the mechanisms involved. We studied a 49-year-old man with symptoms of syringomyelia and syringobulbia lasting 7 years. Esophageal motility studies showed inability to initiate swallowing, esophageal hypomotility, and absence of the lower esophageal sphincter. After decompression of the syrinx by shunting, these abnormalities were corrected, and the patient could once again eat without aspiration. Medullary dysfunction caused by the syrinx was probably responsible for the swallowing difficulties.

Lymphocyte populations in childhood idiopathic thrombocytopenic purpura

Altered immune function has previously been reported in children with idiopathic thrombocytopenic purpura (ITP). Some prior studies have shown that acute and chronic ITP might be differentiated by certain immunologic tests. We investigated lymphocyte subsets in 12 children with ITP (six acute and six chronic) using murine monoclonal antibodies. Although the mean percentages of B lymphocytes and total number of T lymphocytes, suppressor T cells, and helper T cells were similar in patients with acute and chronic ITP and in controls, the values for many children with ITP fell outside of the normal range. The distribution of values was similar among the patients with acute and chronic ITP. These results suggest a heterogeneous nature of immune-mediated thrombocytopenia in childhood.