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Gunn E, Powers JM, Rahman AF, Bemrich-Stolz C, Mennemeyer S, Lebensburger JD, Wilson HP. Diagnosis and management of isolated neutropenia: A survey of pediatric hematologist oncologists. Pediatr Blood Cancer 2023; 70:e29946. [PMID: 36495229 DOI: 10.1002/pbc.29946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/05/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Isolated neutropenia is a common referral to pediatric hematology oncology (PHO) physicians. There are no established consensus guidelines in the diagnosis and management of patients with isolated, asymptomatic, and incidentally discovered neutropenia. METHODS A survey was distributed to PHO physicians on the American Society of Pediatric Hematology Oncology member discussion page to determine the common diagnostic and management decisions regarding patients with isolated neutropenia and to explore beliefs regarding the term "benign ethnic neutropenia." RESULTS One hundred twenty-six PHO attending physicians completed the survey. The most common tests reportedly ordered for this patient population included complete blood cell count (CBC) (98%), peripheral smear (75%), antineutrophil antibody testing (29%), and immunoglobulins (24%). Providers were more likely to order an antineutrophil antibody in toddlers (p = .0085), and antinuclear antibody (ANA) panels in adolescents (p < .001). Half of providers do not request additional CBCs prior to their initial consultation, and most suggest referring patients with mild neutropenia after confirming a declining absolute neutrophil count (ANC) (51%). The three most important factors influencing ongoing follow-up included: history of recurrent/severe infections (98%), family history of blood disorders (98%), and more severe/progressively worsening neutropenia (97%). Seventy percent of respondents have diagnosed patients with "benign ethnic neutropenia," and 75% support replacement of the term to "typical neutrophil count with Fy(a-/b-) status," if confirmed with red cell phenotyping. CONCLUSION We identified practice patterns of PHO physicians for the diagnosis and management of patients referred for asymptomatic and isolated neutropenia. These data provide the framework to conduct cost-effectiveness studies.
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Affiliation(s)
- Elizabeth Gunn
- Division of Pediatric Hematology Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jacquelyn M Powers
- Division of Pediatric Hematology Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Birmingham, Alabama, USA
| | - Akm Fazlur Rahman
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Christina Bemrich-Stolz
- Division of Pediatric Hematology Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Stephen Mennemeyer
- School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey D Lebensburger
- Division of Pediatric Hematology Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Hope P Wilson
- Division of Pediatric Hematology Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Aluri J, Bach A, Kaviany S, Chiquetto Paracatu L, Kitcharoensakkul M, Walkiewicz MA, Putnam CD, Shinawi M, Saucier N, Rizzi EM, Harmon MT, Keppel MP, Ritter M, Similuk M, Kulm E, Joyce M, de Jesus AA, Goldbach-Mansky R, Lee YS, Cella M, Kendall PL, Dinauer MC, Bednarski JJ, Bemrich-Stolz C, Canna SW, Abraham SM, Demczko MM, Powell J, Jones SM, Scurlock AM, De Ravin SS, Bleesing JJ, Connelly JA, Rao VK, Schuettpelz LG, Cooper MA. Immunodeficiency and bone marrow failure with mosaic and germline TLR8 gain of function. Blood 2021; 137:2450-2462. [PMID: 33512449 PMCID: PMC8109013 DOI: 10.1182/blood.2020009620] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/10/2020] [Indexed: 12/17/2022] Open
Abstract
Inborn errors of immunity (IEI) are a genetically heterogeneous group of disorders with a broad clinical spectrum. Identification of molecular and functional bases of these disorders is important for diagnosis, treatment, and an understanding of the human immune response. We identified 6 unrelated males with neutropenia, infections, lymphoproliferation, humoral immune defects, and in some cases bone marrow failure associated with 3 different variants in the X-linked gene TLR8, encoding the endosomal Toll-like receptor 8 (TLR8). Interestingly, 5 patients had somatic variants in TLR8 with <30% mosaicism, suggesting a dominant mechanism responsible for the clinical phenotype. Mosaicism was also detected in skin-derived fibroblasts in 3 patients, demonstrating that mutations were not limited to the hematopoietic compartment. All patients had refractory chronic neutropenia, and 3 patients underwent allogeneic hematopoietic cell transplantation. All variants conferred gain of function to TLR8 protein, and immune phenotyping demonstrated a proinflammatory phenotype with activated T cells and elevated serum cytokines associated with impaired B-cell maturation. Differentiation of myeloid cells from patient-derived induced pluripotent stem cells demonstrated increased responsiveness to TLR8. Together, these findings demonstrate that gain-of-function variants in TLR8 lead to a novel childhood-onset IEI with lymphoproliferation, neutropenia, infectious susceptibility, B- and T-cell defects, and in some cases, bone marrow failure. Somatic mosaicism is a prominent molecular mechanism of this new disease.
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Affiliation(s)
| | - Alicia Bach
- Division of Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Saara Kaviany
- Pediatric Hematology Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Luana Chiquetto Paracatu
- Division of Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Maleewan Kitcharoensakkul
- Division of Rheumatology/Immunology and
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Magdalena A Walkiewicz
- Centralized Sequencing Initiative, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Christopher D Putnam
- Department of Medicine, University of California School of Medicine, San Diego, La Jolla, CA
- San Diego Branch, Ludwig Institute for Cancer Research, La Jolla, CA
| | - Marwan Shinawi
- Division of Genetics and Genomic Medicine, Department of Pediatrics and
| | | | - Elise M Rizzi
- Division of Allergy and Immunology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | | | | | | | - Morgan Similuk
- Centralized Sequencing Initiative, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Elaine Kulm
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research sponsored by the National Cancer Institute, Frederick, MD
| | | | - Adriana A de Jesus
- Translational Autoinflammatory Diseases Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Raphaela Goldbach-Mansky
- Translational Autoinflammatory Diseases Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Yi-Shan Lee
- Division of Anatomic and Molecular Pathology and
| | - Marina Cella
- Division of Immunology, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO
| | - Peggy L Kendall
- Division of Allergy and Immunology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
- Division of Immunology, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO
| | - Mary C Dinauer
- Division of Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Jeffrey J Bednarski
- Division of Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Christina Bemrich-Stolz
- Division of Hematology and Oncology, Department of Pediatrics, University of Alabama School of Medicine, Birmingham, AL
| | - Scott W Canna
- Division of Pediatric Rheumatology and RK Mellon Institute, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh and University of Pittsburgh, Pittsburgh, PA
| | - Shirley M Abraham
- Division of Hematology and Oncology, Department of Pediatrics, University of New Mexico, Albuquerque, NM
| | | | - Jonathan Powell
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE
| | - Stacie M Jones
- Division of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR
| | - Amy M Scurlock
- Division of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR
| | - Suk See De Ravin
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD; and
| | - Jack J Bleesing
- Division of Bone Marrow Transplantation and Immunodeficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - James A Connelly
- Pediatric Hematology Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - V Koneti Rao
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD; and
| | - Laura G Schuettpelz
- Division of Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
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Nagalapuram V, McCall D, Palabindela P, Howard TH, Bemrich-Stolz C, Lebensburger J, Hilliard L, Wilson HP. Outcomes of Isolated Neutropenia Referred to Pediatric Hematology-Oncology Clinic. Pediatrics 2020; 146:peds.2019-3637. [PMID: 32883808 DOI: 10.1542/peds.2019-3637] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Children with isolated neutropenia (absolute neutrophil count [ANC] <1500/μL) are frequently referred to pediatric hematology and oncology clinics for further diagnostic evaluation. Scant literature exists on interventions and outcomes for isolated neutropenia. We hypothesized that children will have resolution of their neutropenia without the need for intervention(s) by a pediatric hematologist and oncologist. METHODS We performed a 5.5-year institutional review board-approved retrospective chart review of children referred to our pediatric hematology and oncology clinics for isolated neutropenia. Neutropenia was categorized as mild (ANC of 1001-1500/μL), moderate (ANC of 500-1000 μL), severe (ANC of 201-500/μL), or very severe (ANC of ≤200/μL). RESULTS Among 155 children referred with isolated neutropenia, 45 (29%) had mild neutropenia, 65 (42%) had moderate neutropenia, 30 (19%) had severe neutropenia, and 15 (10%) had very severe neutropenia. Only 29 (19%) children changed to an ANC category lower than their initial referral category. At a median follow-up of 12 months, 101 children had resolution of neutropenia, 40 children had mild neutropenia, 10 children had moderate neutropenia, 3 children had severe neutropenia, and 1 patient had very severe neutropenia. A specific diagnosis was not identified in most (54%) children. The most common etiologies were viral suppression (16%), autoimmune neutropenia (14%), and drug-induced neutropenia (8%). Black children had a 3.5 higher odds of having persistent mild neutropenia. Six (4%) children received granulocyte colony-stimulating factor therapy. CONCLUSIONS Most children referred for isolated neutropenia do not progress in severity and do not require subspecialty interventions or hospitalizations.
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Affiliation(s)
- Vishnu Nagalapuram
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama; and
| | - David McCall
- MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Prasannalaxmi Palabindela
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Thomas H Howard
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Christina Bemrich-Stolz
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Jeffrey Lebensburger
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Lee Hilliard
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Hope P Wilson
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama; and
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Hilliard LM, Kulkarni V, Sen B, Caldwell C, Bemrich-Stolz C, Howard TH, Brandow A, Waite E, Lebensburger JD. Red blood cell transfusion therapy for sickle cell patients with frequent painful events. Pediatr Blood Cancer 2018; 65:e27423. [PMID: 30152184 PMCID: PMC6193814 DOI: 10.1002/pbc.27423] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/02/2018] [Accepted: 08/03/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recurrent pain events or chronic pain are among the most common complications of sickle cell disease. Despite attempts to maximize adherence to and dosing of hydroxyurea, some patients continue to suffer from pain. Our institution developed a program to initiate chronic red blood cell transfusions for one year in patients clinically deemed to have high healthcare utilization from sickle cell pain, despite being prescribed hydroxyurea. PROCEDURE An institutional review board approved retrospective study to evaluate the health outcomes associated with a one-year red blood cell transfusion protocol in sickle cell patients experiencing recurrent pain events as compared with the health outcomes for these patients in the one year prior to receiving transfusion therapy. We performed a matched-pair analysis using a Wilcoxon signed rank to determine the impact of transfusion therapy on clinic visits, emergency department visits, hospital admissions, hospitalization days, and opioid prescriptions filled. RESULTS One year of transfusion therapy significantly reduced the number of total emergency department visits for pain (6 vs 2.5 pain visits/year, P = 0.005), mean hospitalizations for pain (3.4 vs 0.9 pain admissions/year), and mean hospital days per year for pain crisis (23.5 vs 4.5, P = 0.0001), as compared with the one year prior to transfusion therapy. We identified no significant difference in opioid prescriptions filled during the year of transfusion therapy. CONCLUSION Patients with frequent pain episodes may benefit from one year of transfusion therapy.
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Affiliation(s)
- Lee M. Hilliard
- University of Alabama at Birmingham, Division of Pediatric Hematology Oncology
| | - Varsha Kulkarni
- University of Alabama at Birmingham, Division of Pediatric Hematology Oncology
| | - Bisakha Sen
- University of Alabama at Birmingham Department of Health Care Organization & Policy
| | | | | | - Thomas H Howard
- University of Alabama at Birmingham, Division of Pediatric Hematology Oncology
| | | | - Emily Waite
- University of Alabama at Birmingham, Division of Pediatric Hematology Oncology
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Payne J, Aban I, Hilliard LM, Madison J, Bemrich-Stolz C, Howard TH, Brandow A, Waite E, Lebensburger JD. Impact of early analgesia on hospitalization outcomes for sickle cell pain crisis. Pediatr Blood Cancer 2018; 65:e27420. [PMID: 30151977 PMCID: PMC6192851 DOI: 10.1002/pbc.27420] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 07/27/2018] [Accepted: 07/30/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Painful events are the leading cause of hospitalizations for patients with sickle cell disease. Individualized pain plans targeting patient-specific maximum opioid dosing may shorten hospitalization length and are recommended by national guidelines. Prior to implementing individualized sickle cell pain plans, we tested the hypothesis that a shorter time to achieve a maximum opioid dose would improve hospitalization outcomes. PROCEDURE Two-year IRB-approved, retrospective study of pediatric patients admitted for vaso-occlusive crisis (VOC). We recorded the emergency department admission time, order entry time for the maximum opioid dose during the hospitalization, and time of discharge orders. We categorized patients as infrequent if they required <3 admissions for VOC over two years and patients as frequent if they required ≥3 admissions for VOC over two years. To account for multiple admissions, generalized linear modeling was performed. RESULTS We identified 236 admissions for acute pain observed in 108 patients. Achieving an earlier maximum opioid dose was significantly associated with shorter length of hospitalization for frequent and infrequent pain patients (both P ≤ 0.0001). As total hospitalization length can be impacted by the time a maximum opioid order was placed, we also analyzed hospitalization length after the maximum opioid order was placed. Frequent pain patients who achieved earlier analgesia had a significantly shorter hospitalization from the time the maximum opioid order was placed (P = 0.03) while no association was found for infrequent pain patients (P = 0.84). CONCLUSIONS Early achievement of maximum analgesia improved hospitalization outcomes and warrant further investigation in prospective studies of individualized pain plans.
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Affiliation(s)
- Jason Payne
- University of Alabama at Birmingham, Division of Pediatric Hematology Oncolog
| | - Inmaculada Aban
- University of Alabama at Birmingham, Department of Biostatistics
| | - Lee M. Hilliard
- University of Alabama at Birmingham, Division of Pediatric Hematology Oncolog
| | - Jennifer Madison
- University of Alabama at Birmingham, Division of Pediatric Hematology Oncolog
| | | | - Thomas H Howard
- University of Alabama at Birmingham, Division of Pediatric Hematology Oncolog
| | - Amanda Brandow
- Medical College of Wisconsin, Division of Pediatric Hematology Oncology
| | - Emily Waite
- University of Alabama at Birmingham, Division of Pediatric Hematology Oncolog
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Schlappi C, Kulkarni V, Palabindela P, Bemrich-Stolz C, Howard T, Hilliard L, Lebensburger J. Outcomes in Mild to Moderate Isolated Thrombocytopenia. Pediatrics 2018; 142:peds.2017-3804. [PMID: 29891565 PMCID: PMC6317551 DOI: 10.1542/peds.2017-3804] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2018] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES Incidental isolated mild to moderate thrombocytopenia is a frequent laboratory finding prompting a referral to pediatric hematology-oncology. We tested the hypothesis that patients with isolated asymptomatic mild thrombocytopenia would not progress to require an intervention from a pediatric hematologist-oncologist. METHODS This is a 5-year retrospective review of 113 patients referred to pediatric hematology-oncology for isolated thrombocytopenia. Initial, lowest, and current platelet counts along with clinical course and need for interventions were recorded. Thrombocytopenia was categorized as mild (platelet count: 101-140 × 103/μL), moderate (platelet count: 51-100 × 103/μL), severe (platelet count: 21-50 × 103/μL), and very severe (platelet count: ≤20 × 103/μL). RESULTS Eight of 48 patients (17%) referred for initial mild isolated thrombocytopenia progressed to moderate thrombocytopenia at 1 visit. At present, 2 of these patients have moderate thrombocytopenia, 17 remain with mild thrombocytopenia, and 29 patients have resolved thrombocytopenia. Nine of 65 patients (14%) referred for moderate thrombocytopenia progressed to severe or very severe thrombocytopenia on 1 occasion. At present, no patients have severe thrombocytopenia, 18 remain with moderate thrombocytopenia, 14 improved to mild thrombocytopenia, and 33 have resolved thrombocytopenia. Only 3 patients required interventions from a hematologist, whereas 10 patients required therapy from other subspecialties. CONCLUSIONS We only identified 3 patients (3%) with mild to moderate thrombocytopenia who required an intervention from a hematologist to improve platelet counts. Patients with isolated mild thrombocytopenia with a normal bleeding history and physical examination findings frequently have normalized their platelet counts within 1 month.
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Affiliation(s)
| | | | | | | | | | | | - Jeffrey Lebensburger
- Division of Pediatric Hematology Oncology. University of Alabama at Birmingham, Birmingham, Alabama
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