Atrioventricular septal defect in the fetus--associated conditions and outcome in 246 cases

PURPOSE

To evaluate the associated conditions and the outcome of atrioventricular septal defects (AVSD) detected in fetal life.

MATERIALS AND METHODS

Retrospective review of all cases of AVSD detected prenatally between 1998 and 2006 in two tertiary referral centers in Germany.

RESULTS

246 cases of AVSD were detected in the study period: 129 (52.4 %) chromosomal anomalies; 72 (29.3 %) heterotaxy syndromes; 17 (6.9 %) non-chromosomal malformation syndromes; 16 (6.5 %) isolated complex cardiac malformations; 5 (2.0 %) singular extracardiac malformations; 7 (2.8 %) isolated AVSD. Chromosomal anomalies were detected significantly earlier in pregnancy (p < 0.01). Associated intracardiac malformations were present in 109/246 (44.3 %) cases. Fetuses with trisomy 21 were significantly associated with balanced ventricular morphology and isolated AVSD (p < 0.01). Among the 246 cases, 144 (58.5 %) underwent termination of pregnancy, 18 (7.3 %) died in utero, 17 (6.9 %) in the neonatal period and 19 (7.7 %) in infancy. Forty-eight children (19.5 %) survived with a mean follow-up of 34.94 +/- 18.6 months. After exclusion of lethal malformations, the survival rate among live births was 64.9 % (48 / 74). Fetuses with trisomy 21 had significantly better survival rates among continued pregnancies (p < 0.01) and significantly higher rates of successful biventricular repair among survivors who received their final corrective procedure (p < 0.01) than fetuses with normal karyotypes.

CONCLUSION

Among fetuses with AVSD, those with trisomy 21 are detected earlier in pregnancy, have less distorted cardiac anatomy, higher rates of biventricular repair and better survival rates. Due to the limited sample size in euploid fetuses, it remains unclear whether this apparent protection afforded to Down syndrome accounts also for cohorts with isolated and balanced AVSD.

Orofaciodigital syndrome Type IV (Mohr-Majewski): early prenatal diagnosis in siblings

We report the sonographic and autopsy findings in two sibling fetuses with autosomal recessive orofaciodigital syndrome (OFDS) Type IV (Mohr-Majewski) diagnosed at 11-13 weeks' gestation. The first-trimester anomaly scan showed a markedly increased nuchal translucency (NT) thickness in both fetuses (4.7 mm and 5.1 mm). Both fetuses had multiple anomalies involving the brain, cranium, heart and skeletal system and their karyotypes were normal. The pregnancies were terminated and the autopsies showed findings consistent with Mohr-Majewski syndrome. These cases show the overlap between OFDS Type II (Mohr) and lethal short-rib-polydactyly syndrome Type II (Majewski) and confirm both the autosomal recessive inheritance of the condition and our ability to diagnose it early in pregnancy using detailed fetal ultrasonography.

[Cholestasis-associated hepatopathies in neonates and infants]

Cholestasis in neonates and infants frequently confronts pediatricians and pathologists with diagnostic problems. A specific feature of the liver in neonates is the ability to react to different causative factors with a non-specific hepatitis-like picture, the so-called neonatal hepatitis. A diagnostic discrimination of the various diseases is histologically only possible with close attention to typical morphologic features. Thus, extrahepatic biliary obstructions, such as atresia or stenosis of the hepatic duct or choledochal cysts present with portal bile duct proliferation and signs of bile retention in the neoducts. In Alagille syndrome (arteriohepatic dysplasia), however, paucity of intrahepatic bile ducts is an important diagnostic feature. Metabolic disorders, such as fructosemia and galactosemia are additionally associated with steatosis. Knowledge of the clinical course and laboratory and imaging data are necessary to make the definitive diagnosis in synopsis with the morphologic findings and requires a close co-operation between the pediatrician and the pathologist.

Intrapericardial teratoma in the newborn--3D-echocardiography and course of disease

Intrapericardial teratoma is a rare tumour which may become life threatening when it causes mediastinal compression. Early sonographic detection and careful evaluation is necessary for further management. In this paper, we present a case with a large intrapericardial teratoma diagnosed in utero (25 + 0 weeks). After birth, 3D-echocardiography was particularly helpful in obtaining a comprehensive view of the three-dimensional structure of this complex tumour, in order to determine tumour extension and attachment before surgical excision. This case illustrates the opportunities which new, noninvasive echocardiographic tools create to aid therapeutic management and surgical therapy of critically ill patients.

Absence of ductus venosus-importance of umbilical venous drainage site

OBJECTIVE

To evaluate the conditions associated with absent ductus venosus (ADV) diagnosed by prenatal ultrasonography.

METHODS

Retrospective review of 23 cases with ADV diagnosed in two tertiary referral centers with a general screening policy concerning Doppler assessment of the ductus venosus. The results are discussed together with 63 cases from a review of the literature.

RESULTS

In 19 fetuses the umbilical vein connected to the portal sinus, while the remaining four fetuses had extrahepatic umbilical venous drainage. Associated anomalies were present in 15 out of 23 fetuses: complex malformation syndromes (n = 6), chromosomal anomalies (n = 4), isolated cardiac defects (n = 4) and isolated extracardiac anomalies (n = 1). Eight fetuses had either no associated anomalies or minor anomalies. Hydropic changes were present in 12 of the 23 fetuses. In common with the reviewed cases, the presence of cardiac malformations, complex non-chromosomal malformation syndromes and hydrops was significantly associated with intrauterine or postnatal death while the type of umbilical venous drainage was not significantly different between survivors and non-survivors. However, among fetuses with no or minor associated anomalies the outcome was significantly better in the group without liver bypass.

CONCLUSIONS

ADV is significantly associated with fetal cardiac and extracardiac anomalies, aneuploidies and hydrops. Fetuses with liver bypass have an additional risk of developing congestive heart failure that significantly affects outcome, even if the fetal cardiovascular anatomy is otherwise normal. ADV without liver bypass seems to have a more favorable prognosis if it is not associated with other malformations.

The syndrome of right isomerism -- prenatal diagnosis and outcome

OBJECTIVE

To evaluate the accuracy of the prenatal diagnosis of right isomerism and to assess possible diagnostic and prognostic markers.

METHODS

Retrospective review of all cases of right isomerism identified between 1989 and 2003 in two tertiary referral centres in Germany.

RESULTS

Among 21 foetuses, 16 had a correct prenatal diagnosis of right isomerism. 19 showed different types of viscerocardiac heterotaxy, 12 of them in combination with juxtaposition of vena cava inferior and aorta. 20 had cardiac defects, with a high prevalence of atrioventricular septal defect (CAVSD) (62 %), right outflow tract obstruction (48 %), anomalous pulmonary venous return (33 %) and double outlet right ventricle (29 %). 4 out of 6 cases with total anomalous pulmonary venous return were overseen on prenatal ultrasound. Only 6 children survived. The highest loss occurred in the neonatal period. Two out of 6 survivors underwent single ventricle palliation, while another two had a biventricular repair. One child is awaiting mitral valve replacement. The remaining case has no cardiac defect and lives with supraventricular re-entry tachycardia. Only the presence of CAVSD was significantly correlated with non-survival (p < 0.05).

CONCLUSIONS

The prenatal diagnosis of right isomerism remains a difficult task. Important sonographic markers are viscerocardiac heterotaxy, complex cardiac malformations and juxtaposition of vena cava inferior and aorta. Special attention has to be paid to the pattern of pulmonary venous drainage, as it is often misdiagnosed. The mortality in neonates is high, especially in the presence of CAVSD. Survivors suffer from significant morbidity.

Prenatal diagnosis of persistent left superior vena cava and its associated congenital anomalies

OBJECTIVE

To evaluate the associated conditions and the outcome of persistent left superior vena cava (PLSVC) detected in fetal life.

METHODS

This was a retrospective review of all cases of PLSVC detected prenatally between 1998 and 2004 in two tertiary referral centers in Germany. Patient charts, ultrasound video recordings and still frames of all cases were reviewed for associated conditions and outcome.

RESULTS

Eighty-two cases of PLSVC were detected in the study period. Thirty-seven cases (45%) were associated with heterotaxy syndromes, 19 (23%) with isolated cardiac malformations, seven (9%) with aneuploidy, six (7%) with complex malformation syndromes and six (7%) with isolated extracardiac malformations. Seven cases (9%) had no associated condition. Eighty-three percent of the fetuses in this series had associated cardiac malformations; the most frequent cardiac malformations in those with heterotaxy syndromes were complete atrioventricular septal defect (75%) and right outflow tract obstruction (58%). After exclusion of cases with heterotaxy, most congenital heart defects were ventricular septal defects (41%) and coarctation (34%). The outcome of PLSVC was determined solely by the associated conditions. After exclusion of terminated cases, heterotaxy syndromes as well as complete atrioventricular septal defects were associated significantly with perinatal and infant death. In contrast, all cases with isolated PLSVC or associated correctable extracardiac malformations survived and were doing well at the time of writing.

CONCLUSIONS

PLSVC detected in fetal life has to be followed by a meticulous inspection of the fetal anatomy as it is frequently associated with heterotaxy syndromes, other cardiac/non-cardiac malformations and aneuploidy that determine the outcome. Isolated PLSVC is a benign vascular anomaly and may not affect the outcome.

Prenatal diagnosis and therapy of upper extremity vascular malformation causing high cardiac output and Kasabach-Merritt sequence: a report of two cases

We present two cases of upper extremity vascular malformation causing a high output state in the prenatal period. One fetus responded well to transplacental digitalis treatment. Both newborns had a Kasabach-Meritt sequence including anemia and thrombocytopenia. Postpartum treatment included successful interventional occlusion of the main feeding arteries and subsequent surgical removal of the tumor.

CT imaging of pulmonary lobar interstitial emphysema in a spontaneous breathing preterm infant

Pulmonary interstitial emphysema (PIE) is a well-recognized severe complication of neonatal respiratory distress syndrome (RDS). However, its occurrence under spontaneous breathing conditions has been described rarely. We present a case of PIE of the left upper lung lobe in an extremely low birth weight infant. Recurrent episodes of spontaneous pneumothorax led to the diagnosis, which was confirmed by histopathology. Plain chest X-ray did not show typical signs of PIE, whereas extra-alveolar air accumulation could be visualized by helical computed tomography (CT)-scan. We stress the role of predispositional factors increasing the risk of PIE development in spontaneous breathing preterm infants.

[Congenital cystic adenomatoid malformation--clinical spectrum and management]

Congenital cystic adenomatoid malformation (CCAM) is one of the most frequent dysplasias of the lung. Diagnosis is often suspected in utero and urges obstetricians, pediatricians, and pediatric surgeons to make appropriate management decisions as to an optimal management for the affected patients. We report on a preterm baby with a gestational age of 33 weeks, suffering from hydrops fetalis and postnatal respiratory distress syndrome, a two-year old boy with clinical signs of a foreign body aspiration, and a seven-year old boy with a funnel chest. In each case, surgical resection was performed, the histology revealing CCAM. Our case report describes the broad clinical spectrum of CCAM. An algorithm is presented, helping to make diagnostic and therapeutic decisions.

Peutz-Jeghers syndrome: four novel inactivating germline mutations in the STK11 gene. Mutations in brief no. 227. Online

The diagnosis of Peutz-Jeghers syndrome is based on the occurrence of hamartomatous gastrointestinal polyps and perioral pigment spots. In view of the development of hamartomatous polyps in several syndromes and the variability of pigment spots in Peutz-Jeghers patients, identification of affected individuals is difficult. Recently, germline mutations in the STK11 gene have been reported as a molecular cause of Peutz-Jeghers syndrome. We present four novel inactivating mutations identified by direct sequencing of all 9 exons of the STK11 gene in 4 patients suggestive of Peutz-Jeghers syndrome: three frameshift mutations (125-137del; 474-480del; 516-517insT) and one nonsense mutation (Q220X). Our data obtained in these patients and in those reported previously emphasize the diagnostic value of histological discrimination between different types of hamartomatous polyps and of molecular analysis, particularly in cases with no family history of the disease.

First-trimester fetal heart block: a marker for cardiac anomaly

BACKGROUND

Fetal heart block in the second and third trimesters may be caused by transplacental passage of auto-antibodies or cardiac defects. Little is known about the etiology of first-trimester fetal heart block.

MATERIALS AND METHODS

Fetal heart block was diagnosed in four patients (negative antibody serology) referred for first-trimester sonographic evaluation of increased fetal nuchal fold thickness with bradycardia. Two-dimensional echocardiography was complemented by color Doppler flow imaging of the fetal heart. Fetal arrhythmia was verified by M-mode, pulsed wave Doppler and/or color M-mode echocardiography.

RESULTS

All fetuses had congenital heart disease, atrioventricular valve regurgitation, heart block and edema. Autopsy confirmed heterotaxy in three cases (left atrial isomerism with atrial septal defect; left isomerism with double-outlet right ventricle, great artery malposition and ventricular septal defect. The third case had dextrocardia with atrioventricular canal defect and the fourth case dextrocardia with great artery transposition.

CONCLUSION

First-trimester fetal bradycardia may result from heart block of the type associated with complex congenital heart disease. Accelerated edema formation in this setting may be the basis of nuchal edema formation. First-trimester fetal echocardiography offers the potential for early diagnosis and intervention in these cases with poor prognosis.

Peutz-Jeghers syndrome: four novel inactivating germline mutations in the STK11 gene. Mutations in brief no. 227. Online

The diagnosis of Peutz-Jeghers syndrome is based on the occurrence of hamartomatous gastrointestinal polyps and perioral pigment spots. In view of the development of hamartomatous polyps in several syndromes and the variability of pigment spots in Peutz-Jeghers patients, identification of affected individuals is difficult. Recently, germline mutations in the STK11 gene have been reported as a molecular cause of Peutz-Jeghers syndrome. We present four novel inactivating mutations identified by direct sequencing of all 9 exons of the STK11 gene in 4 patients suggestive of Peutz-Jeghers syndrome: three frameshift mutations (125-137del; 474-480del; 516-517insT) and one nonsense mutation (Q220X). Our data obtained in these patients and in those reported previously emphasize the diagnostic value of histological discrimination between different types of hamartomatous polyps and of molecular analysis, particularly in cases with no family history of the disease.

[Duplication of the stomach as a rare cause of cystic epigastric tumor]

Duplications of the gastrointestinal tract are congenital anomalies seen in about 0.2% of all children. These include the rare gastric duplications. Latter diagnosis is usually made in the first months after birth on recurrent vomiting by detection of an abdominal tumor. The most important imaging modality is ultrasonography. The case of a prematurely born child weighing 1900 g is presented in whom at the age of three weeks a gastric duplication of the greater curvature was diagnosed and who was successfully treated by resection. The postoperative follow-up for 24 months was uncomplicated.

[Peliosis hepatis with hepato-pulmonary syndrome]

Sinusoidal dilatation is a hallmark of peliosis hepatis, a rare vascular disorder that can be either drug induced or of infectious origin. Here we report a patient with peliosis hepatis of unknown etiology. An hepato-pulmonary syndrome developed which was reversible following liver transplantation.

Results of chromosomal analysis in fetuses with cardiac anomalies as diagnosed by first- and early second-trimester echocardiography

Chromosomal analyses were performed in 36 fetuses with cardiac anomalies diagnosed by echocardiography at 11 + 1 to 15 + 6 weeks of gestation. Karyotyping was successful in 35 cases and 17 (48.6%) had anomalies, including five with Turner's syndrome, seven with trisomy 18, four with trisomy 21 and one with triploidy. The commonest cardiac anomaly observed in trisomy 21 was a complete atrioventricular canal; in trisomy 18 was ventricular septal defect; in Turner's syndrome was a hypoplastic aortic arch in combination with hypoplasia of the left ventricle and left ventricular outflow tract; and in the case of triploidy was a ventricular septal defect. These findings confirm the opinion that, in fetuses with chromosomal anomalies, there is a high incidence of cardiac defects. Furthermore, there is a distinct pattern of cardiac defects associated with each chromosomal anomaly.

Early diagnosis of fetal congenital heart disease by transvaginal echocardiography

Fetal echocardiography was performed using a high-frequency vaginal ultrasound probe in 114 singleton pregnancies between 11 and 16 weeks of gestation. The four-chamber view with both atria, atrioventricular valves and ventricles as well as the origin and double-crossing of aorta and pulmonary trunk could always be demonstrated from the 13th week onwards. In 12 of 13 cases, cardiac malformations were diagnosed in the first trimester. Only in one case was transabdominal echocardiography necessary at 20 weeks to make the diagnosis. In several cases, however, additional malformations were overlooked, in particular anomalies of the great arteries, such as coarctation of the aorta. Therefore, the accuracy of second-trimester transabdominal echocardiography is markedly higher. Because of the lower diagnostic accuracy, the high costs of equipment and the high training demanded of the examiner, first-trimester transvaginal echocardiography should be restricted to the high-risk fetus, i.e.: (1) Cases with other fetal anomalies very often associated with cardiac defects, such as nuchal edema and hygroma, non-immune hydrops, omphalocele, situs, inversus, or persisting arrythmia; (2) High-risk families with one or more first-degree relatives with cardiac defects are either inherited by Mendelian rules alone, or as part of a rare syndrome; and (3) In pregestational diabetes of the mother.Thus, many severe cardiac defects can be detected or excluded in the first trimester, reducing maternal anxiety. In these high-risk cases, second-trimester echocardiography using the transabdominal route should always be performed because of its distinctly higher diagnostic accuracy.

Steinfeld syndrome: report of a second family and further delineation of a rare autosomal dominant disorder

We report on a fetus with alobar holoprosencephaly, microphthalmia, midline cleft lip and palate, absent nose, dysplastic ears, radial defects, pentalogy of Fallot, unilateral renal aplasia, absent gallbladder, vertebral anomalies, and absence of ribs. The father had a cleft palate, bilateral colobomas of the iris and retina, a bifid uvula, vertebral anomalies, and unilateral congenital hearing loss. His sister had a cleft lip. On the basis of this family and the family reported by Steinfeld [1982], this malformation syndrome can be defined as a rare autosomal dominant syndrome whose main component manifestations are holoprosencephaly, predominantly radial limb deficiency, heart defects, kidney malformations, absence of gallbladder, and vertebral anomalies.

Prenatal diagnosis of atrioventricular canal malformations with up-to-date echocardiographic technology: report of 14 cases

Fourteen fetuses with atrioventricular canal malformations were examined by two-dimensional echocardiography, pulsed-wave Doppler echocardiography, and color Doppler flow mapping. Eleven fetuses had complete and three fetuses had partial atrioventricular canal malformations. Nonimmune hydrops fetalis was associated with six cases, and fetal arrhythmia was seen in three cases. With two-dimensional echocardiography, the atrioventricular canal malformations could be diagnosed accurately. The inclusion of color Doppler flow mapping, however, provided additional hemodynamic information that was important from the prognostic point of view. Incompetence of atrioventricular valves could be demonstrated in 10 of 14 cases by Doppler echocardiography. In nine cases, detailed Doppler echocardiographic evaluation of the regurgitation jet was possible. The proportion of systolic time during which atrioventricular valve insufficiency was demonstrated was related to the occurrence of nonimmune hydrops fetalis. When insufficiency of atrioventricular valves was associated with hydrops (four cases), a pansystolic insufficiency was always present. In cases without hydrops (five), regurgitation was confined to early systole. Thus a reliable method for semiquantitative evaluation of the degree of insufficiency seems to have been found. Moreover, an association appeared to exist between the occurrence of hydrops fetalis and the proportion of atrial area that was taken up by regurgitant jet area, as determined by planimetry in the four-chamber view. Prenatal diagnosis was confirmed by autopsy or neonatal cardiac evaluation. Only one neonate survived in our series. Two were stillborn, four died during the neonatal period, two died during infancy, and pregnancy was electively terminated prematurely in five cases. Eight fetuses were found to have a karyotypic abnormality.

Flow analysis in the pulmonary trunc in fetuses with tetralogy of Fallot by colour Doppler flow mapping; two case reports

Prenatal diagnosis of tetralogy of Fallot by two-dimensional echocardiography, which is based on demonstration of a ventricular septal defect and a large overriding aorta, is difficult. In the majority of cases the main pulmonary artery is small. In utero, there is no pathologically increased degree of the physiological right-ventricular hypertrophy. Colour Doppler flow mapping of reverse flow from the descending aorta via the ductus arteriosus into the main pulmonary artery is easily demonstrated, and provides an indirect sign of severe right-ventricular outlet obstruction. The technique also differentiates between pulmonary stenosis and atresia; the stenotic jet, even small, is identified by demonstration of high velocities and turbulences in the main pulmonary artery.

[Primary and metastatic liver tumors--evaluation of tumor regression and response with regional cytostatic drug therapy by sonography and fine needle puncture histology]

Primary and metastatic hepatic tumours--evaluation of tumour regression or response under regional cytostasis with sonography and fine needle puncture histology. The results obtained through the use of regional liver perfusion with a 5-FU-BCNU application on non-resectable hepatic metastases of colorectal tumours following primary curative removal of the primary tumour and primary hepatocellular carcinomas display comparable results to those specified in the literature after the use of 5-FUDR. The effectivity of the cytostasis regime is checked using histological criteria. The ultrasonically guided fine needle puncture can prove the success of the cytostasis regime on the basis of cytomorphologic criteria more reliably than has been the case up to now. Patients displaying histological signs of tumour regression have a significantly longer survival time than those displaying no signs of regression (12 +/- 9.2 vs 4.5 +/- 2.2 months; p less than 0.05).

First-trimester diagnosis of fetal congenital heart disease by transvaginal two-dimensional and Doppler echocardiography

Until recently, prenatal diagnosis of fetal cardiac malformations was restricted to the second and third trimesters. With the advent of high-frequency transvaginal probes, earlier detection of such malformations is possible. We present a case of nonimmune hydrops fetalis with complete atrioventricular canal defect, insufficiency of atrioventricular valves, and complete heart block at 11 weeks' gestation diagnosed by transvaginal two-dimensional and Doppler echocardiography.

Fetal complete heart block: antenatal diagnosis, significance and management

Complete heart block was diagnosed prenatally in 21 fetuses. Associated structural cardiac defects were present in 18 fetuses, in particular complete atrioventricular canal with atrial isomerism (5 cases), and 'corrected' transposition of the great arteries (4 cases). Maternal systemic lupus erythematosus was proved in only one case. In 11 fetuses, intra-uterine congestive heart failure with the signs of non-immune hydrops fetalis occurred. In all 11 fetuses, the hydrops was associated with a cardiac defect, in particular complete atrioventricular canal with atrial isomerism in 5 cases. A review of the literature confirms that only the association of complete heart block and cardiac malformation can cause intra-uterine congestive heart failure, whereas in the case of fetal complete heart block without cardiac malformation or with prenatally hemodynamically insignificant cardiac malformation, congestive heart failure is rare. Only 30% of newborns with complete heart block have associated cardiac malformations. In our series, however, 86% of the fetuses with complete heart block had cardiac malformations. The most important reason for this percentage discrepancy is that almost all fetuses with associated severe cardiac defects, in particular atrioventricular canal defects, develop heart failure which frequently results in prenatal death. Thus, fetal deaths are not included in pediatric statistics. Nevertheless, fetuses with isolated complete heart block generally do not develop heart failure and in almost all of the cases are born alive.

[Prenatal diagnosis of severe tricuspid valve insufficiency in Ebstein anomaly with pulmonary valve atresia by 2-dimensional color coded Doppler echocardiography]

By the application of all methods of fetal echocardiography the prenatal diagnosis and a prognostically correct assessment was reached in a severe case of Ebstein's anomaly of tricuspid valve associated with pulmonary atresia, severe tricuspid regurgitation, and a hypoplastic main pulmonary artery. It is demonstrated that only the application of two-dimensional color-coded Doppler-echocardiography followed by a spectral-Doppler-echocardiography can result in an accurate evaluation of hemodynamical alterations and thus in the prognostic assessment in the reported case.

[Non-immunologically-induced hydrops fetalis in complete atrioventricular block of the fetus. A summary of 11 prenatally diagnosed cases]

In 11 of 21 fetuses with prenatally diagnosed complete heart block, congestive heart failure with signs of non-immune hydrops fetalis was seen. In all 11 fetuses, cardiac malformations were present: complete atrioventricular canal with levocardia, situs inversus viscerum, and polysplenia: 5 cases; tricuspid atresia with situs inversus viscerum, endocardial fibroelastosis, common atrium with aortic valve atresia, hypoplastic left heart, atrial septal defect of secundum type: one case each. All these cardiac malformations can also cause intrauterine heart failure without heart block except hypoplastic left heart and atrial septal defect. A review of the literature confirms, that only the association between complete heart block and cardiac malformation--in particular AV-canal and endocardial fibroelastosis--can cause an intrauterine congestive heart failure, whereas in the case of fetal complete heart block without cardiac malformation or with prenatally hemodynamically insignificant cardiac malformations--in particular "corrected" transposition of great arteries--a congestive heart failure is rare.

Gliomatosis peritonei with endometriosis externa

A case of gliomatosis peritonei developed 9 years after the removal of an immature ovarian teratoma is reported. An unique association of gliomatosis with endometriosis externa was found without the usual symptoms of endometriosis. The prognosis of gliomatosis is generally excellent and depends on the histological grade of the primary tumor and on the presence of organ metastasis or immature tumor elements in the implants. Pathogenetical aspects of both lesions are discussed briefly.

Listeriosis: a cause of non-immune hydrops fetalis

A case of prenatally diagnosed non-immune hydrops fetalis, that was later shown to be caused by listeriosis, is presented, and the clinical course, as well as the appropriate diagnostic and therapeutic procedures are described. We conclude, that listeriosis should be excluded, whenever a non-immune hydrops fetalis is associated with septicemia, influenza-like illness and fever of unknown origin.

[Retroperitoneal teratoma. A problem in pediatric urology]

We report about diagnosis and therapy of a retroperitoneal teratoma in a six years old boy. Further we discuss the histogenetical origin as well as the histological classification. Considering other localisations, teratomas of the retroperitoneum are relatively (4%) rare. Most teratomas are diagnosed at school-age either coincidently or because of a mass lesion. Size and localisation of the tumor do not give any information about its nature. Even with negative tumor markers (alpha1-fetoprotein, beta-HCG) the tumor should be considered malignant until histology proves the contrary. Due to these facts a careful en bloc extirpation and a thorough histological examination of the tumor are always necessary.

[Adrenal cortex carcinoma in childhood and adolescence]

The presented paper includes the medical records of two girls with adrenal cortical carcinomas on the one hand and the detailed analysis of a collected series of 150 equal cases in pediatric literature on the other hand. In our patients there were a primarily metastatic, non-functioning tumour and a locally invasive, hormone-secreting neoplasm respectively. The latter one produced a Cushing's syndrome with signs of virilization. In this case surgical removal was followed by postoperative irradiation and adjunctive cytostatic therapy with cyclophosphamide and adriamycin for one year. But tumour recurrence occurred within 6 months. A treatment with the antitumour agents aminogluthetimide and o,p' DDD was transiently effective. However drug-induced side effects necessitated the stop of this regimen after 5 months. The analysis of 150 case reports revealed a peak between 1 and 3 years of age, a striking prevalence of the female sex in all age groups, and a metastasizing rate of about 30% at the time of diagnosis. Regional structures, liver and lung were the main locations of metastatic lesions. The occurrence of second primary neoplasms and the association with a group of other conditions particularly congenital disorders have proved to be a remarkable feature of the disease. In primary adrenal cortical tumours the determination of the neoplasm's biological behaviour by morphologic criteria alone can often be very problematical. This fact is especially stressed.

Prenatal diagnosis of genetically determined early manifestation of autosomal dominant polycystic kidney disease?

A case of an unusually early manifestation of autosomal dominant polycystic kidney disease (ADPKD) is reported that was prenatally diagnosed by ultrasound. The ultrasonographic picture showed greatly enlarged kidneys and increased echogenicity that was indistinguishable from cases of autosomal recessive polycystic kidney disease or Meckel syndrome without further information. Because of two further cases of early manifestation of ADPKD within the family reported (brother and cousin), as well as several other "familial" cases reported in the literature, we postulate that genetic factors are involved (modifying alleles). When reported observations of "familial" cases of early manifestations of ADPKD are made, genetic counseling should be considered.

[The thyroid hormone system in mucoviscidosis]

Endocrine disorders do not represent primary manifestations in children with cystic fibrosis. Abnormal thyroid gland function is commonly observed in patients with chronic nonthyroidal illnesses. Serum concentrations of TSH, T4 and T3 were measured and a TRH-stimulation test (200 micrograms Relefact per kg body weight) was performed in 24 patients with CF 6 to 16 1/2 years of age. As compared to the controls, CF patients had increased basal TSH and lower T4 and T3 concentrations. Finally they exhibited higher TRH-stimulated TSH and decreased peripheral T4 and T3. There was no correlation to the nutritional status or the Shwachman scores. In all patients with CF albumin, TBG and TBPA were also normal. Our results indicate a subclinical hypothyroidism in CF. Routine therapy with thyroid hormones is neither necessary nor recommended.

[Familial adenomatosis coli--a precancerous condition]

The presented paper includes the medical records of five children with familial adenomatous polyposis coli on the one hand and the detailed description of the pathologic findings of the disease on the other hand. Particular emphasis is given to the morphologic criteria of the disorder predisposing the affected individuals to development of colorectal cancer at unusually early ages. In the current cases there was a so-called classical presentation of diffuse polyposis in the early and late childhood respectively. The diagnosis was established in supposedly unaffected siblings due to colonoscopy and radiologic procedures. Prophylactic total colectomy was performed in all proven cases. The association with extracolonic tumours has proved to be a remarkable feature of the disease. This fact is especially stressed.

[Endocrine pancreas function in mucoviscidosis]

Patients with cystic fibrosis of the pancreas show an incidence of diabetes mellitus tenfold higher than is found in the general pediatric population. Considering this fact glucagon and insulin responses to oral glucose and intravenous arginine were studied in 22 CF children and adolescents. Some investigated patients had suffered from the disease for ten years and more. On the one hand the results show that pancreatic alpha cell function is normal. The kinetics of endogenous glucagon release are unaltered. On the other hand the data reveal that there is only a defect in the beta cell function consisting in a delayed insulin release selective to glucose whereas responsiveness to other stimuli for example tolbutamide and arginine is undisturbed. Furthermore there is a diminution in insulin-output to oral glucose as well as to intravenous arginine. Yet in patients with normal oral glucose tolerance endogenous insulin secretion is significantly reduced. Their regular carbohydrate tolerance may be a function of the patient's ability to maintain increased receptor numbers in the face of hypoinsulinemia. Despite greater quantities of secreted hormone a degree of relative peripheral insulin insensitivity has developed in the presence of hyperglycemia. This may be a consequence of impaired affinity of the specific target cell receptors. The insulin secretion pattern is proven to be identical to that of chemical diabetes mellitus in adults. Quantitative diminution in arginine stimulated insulin-output has been found to be independent of the degree of carbohydrate intolerance.(ABSTRACT TRUNCATED AT 250 WORDS)

[Malignant pheochromocytoma in childhood and adolescence--clinical case and review of the literature]

In regard to the diagnostic and therapeutic dilemma concerning rare neoplasms in childhood, the presented paper includes the comprehensive description of a malignant pheochromocytoma in a 14-year-old girl on the one hand and the detailed analysis of a collected series of 21 equal cases in pediatric literature on the other hand. In our patient there was in particular a lack of hypertension in spite of proven hypercatecholaminemia, an initially good effect of the post-operative aggressive chemotherapy according to the neuroblastoma study NBL 79 (4b) resulting in a transient reduction of the pulmonary metastases, furthermore a diminuation of the total tumour mass induced by the last applied treatment with the radiopharmaceutical 131I-metaidiobenzylguanidine. The analysis of 21 case reports revealed a peak between 10 and 15 years of age, a striking prevalence of the female sex in all age groups, and a high frequency of metastases (75%) at the time of diagnosis. Two thirds of the primary tumours arose in extra-adrenal sites, about one third occurred in the adrenal gland. The regional lymph nodes, the bone system and the lungs were the main locations of metastatic lesions. The association with a group of other conditions, particularly hypoxemic congenital heart malformations has proved to be a remarkable feature, but not only in the malignant forms.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cortical hyperostoses after long-term prostaglandin E2 therapy]

Cortical hyperostoses are found to be side effects after therapy in early infancy with prostaglandin E1 and E2. Correlation seems to exist between dosage and duration of therapy. Radiologically the lesions cannot be differentiated from Caffey's disease. Pathogenetic relationship of the two diseases is discussed; 62 cases of newborn children with ductal related vitium cordis, who were treated for a short time or for longer with prostaglandin E2 are demonstrated.

Wilms' tumor in the adolescent and adult

Two rare cases of adolescent and adult Wilms' tumors are reported. All pertinent clinical data are presented. Both patients have been treated by radical tumor nephrectomy, irradiation and polychemotherapy. Only 4 patients with such triple treatment have been reported in the literature. The adolescent girl experienced a complete remission, but the 59-year-old patient rapidly deteriorated and died 4 months postoperatively.

[Treatment of initial urinary tract infection in children with cotrifamole and cotrimoxazole. A double-blind study]

28 children with initial episodes of urinary tract infection were treated with cotrimoxazole or cotrifamole (dose ratio 3 : 2) for 14 days in a prospective randomized double blind trial. The two groups did not differ as regards clinical signs. The efficacy and cure rates of each regimen were similar. Laboratory studies (hemoglobin, WBC, liver, and renal function) showed no differences between both groups before and after therapy; an alteration of the laboratory values could not be observed during therapy. The number of children with X-ray abnormalities of kidneys and urinary tract was similar in both groups. During an observation time of up to 12 months after the first urinary tract infection no differences in the number of reinfections and relapses were observed. As a result of this study, we recommend cotrifamole in a lower dose (ratio 2 : 3) than cotrimoxazole for the treatment of urinary tract infection.