Prophylaxis versus episodic treatment to prevent joint disease in boys with severe hemophilia

BACKGROUND

Effective ways to prevent arthropathy in severe hemophilia are unknown.

METHODS

We randomly assigned young boys with severe hemophilia A to regular infusions of recombinant factor VIII (prophylaxis) or to an enhanced episodic infusion schedule of at least three doses totaling a minimum of 80 IU of factor VIII per kilogram of body weight at the time of a joint hemorrhage. The primary outcome was the incidence of bone or cartilage damage as detected in index joints (ankles, knees, and elbows) by radiography or magnetic resonance imaging (MRI).

RESULTS

Sixty-five boys younger than 30 months of age were randomly assigned to prophylaxis (32 boys) or enhanced episodic therapy (33 boys). When the boys reached 6 years of age, 93% of those in the prophylaxis group and 55% of those in the episodic-therapy group were considered to have normal index-joint structure on MRI (P=0.006). The relative risk of MRI-detected joint damage with episodic therapy as compared with prophylaxis was 6.1 (95% confidence interval, 1.5 to 24.4). The mean annual numbers of joint and total hemorrhages were higher at study exit in the episodic-therapy group than in the prophylaxis group (P<0.001 for both comparisons). High titers of inhibitors of factor VIII developed in two boys who received prophylaxis; three boys in the episodic-therapy group had a life-threatening hemorrhage. Hospitalizations and infections associated with central-catheter placement did not differ significantly between the two groups.

CONCLUSIONS

Prophylaxis with recombinant factor VIII can prevent joint damage and decrease the frequency of joint and other hemorrhages in young boys with severe hemophilia A. (ClinicalTrials.gov number, NCT00207597 [ClinicalTrials.gov].).

Molecular genetic analysis of a small bowel primitive neuroectodermal tumor

We present a pediatric peripheral primitive neuroectodermal tumor (pPNET) localized exclusively to the small bowel. The tumor presented in an adolescent male and the diagnosis was confirmed by electron microscopy, CD99 immunopositivity, and molecular genetic analysis that demonstrated an EWS-FLI1 type 2 fusion transcript. This case report and a review of the literature underscore the considerable phenotypic overlap in EWS-related tumors in this site and the necessity for molecular genetic analysis to permit accurate classification.

Hepatoblastoma in a neonate: a hypervascular presentation mimicking hemangioendothelioma

Congenital heart failure in the neonate supported by classic imaging findings may allow the implementation of medical therapy for presumed hemangioendothelioma without obtaining a tissue diagnosis. This case report describes a neonate with these classic clinical and radiographic findings but who underwent surgery for failing medical treatment and was diagnosed as having a hepatoblastoma by pathology. This case supports the need to obtain tissue confirmation before beginning medical therapy.

Topical absorption of isopropyl alcohol induced cardiac and neurologic deficits in an adult female with intact skin

Topical exposure to isopropyl alcohol has been reported in the literature to be toxic if sufficient isopropyl alcohol is absorbed (1-5). A clinical case is reported where a 48-y-old female presented with multiple unexplained cardiac and neurological deficits. The woman had developed the deficits over a 6-mo period in which she had been soaking towels with isopropyl alcohol and applying then to her skin overnight to ease arm pain she was experiencing. Cessation of the isopropyl alcohol exposure resolved her deficits within 3 d. A controlled repeat dermal exposure to isopropyl alcohol under clinical observation reproduced the deficits noted with corresponding serum and urine concentrations of isopropyl alcohol and acetone. Cessation of topical isopropyl alcohol exposure lead to subsequent resolution of all toxicities.

ERCP in the management of pediatric pancreatitis

BACKGROUND

Although ERCP is commonly performed in children, the effect of findings at ERCP on the subsequent management of pediatric pancreatitis is unknown.

METHODS

We retrospectively reviewed charts to determine the impact of ERCP on the management of recurrent acute or chronic pancreatitis in 17 consecutive children (3 boys and 14 girls, 3 to 16 years, mean 11.2 years) with recurrent acute (n = 13) or chronic pancreatitis (n = 4) who underwent ERCP. Radiographs were reviewed in a blinded manner, and the effect of ERCP findings on subsequent management was determined.

RESULTS

In 16 of 17 patients (94%), the pancreatic duct was successfully visualized. Of the 16 studies, 9 (56%) had abnormal findings. A change in therapy occurred in all 9 patients as a result of the findings at ERCP. Of the 7 patients with a prior abnormal CT or ultrasound, 5 (71%) had an abnormal ERCP, all resulting in a change in therapy. Three of the 9 patients (33%) without radiographic abnormalities had an abnormal ERCP that, in each case, resulted in a change in therapy. Overall, findings at ERCP altered therapy in 52% of pediatric patients studied with recurrent acute or chronic pancreatitis. A prior abnormal CT had a high predictive value with respect to ERCP resulting in a change in management (83%).

CONCLUSIONS

ERCP is useful in the management of pediatric recurrent acute or chronic pancreatitis; abnormalities are found at a rate similar to those found in adults.

Successful management with octreotide of a child with L-asparaginase induced hemorrhagic pancreatitis

BACKGROUND

Octreotide is a synthetic somatostatin analogue which has been suggested for use in the management of acute pancreatitis. While studies have looked at octreotide use in the setting of pancreatitis due to chronic alcohol use or trauma, little is known of its role in management of drug induced acute pancreatitis; particularly in the pediatric setting.

PATIENTS AND METHODS

We present a case of a 5 1/2-year-old white female who developed severe, necrotizing, hemorrhagic pancreatitis with pseudocyst formation secondary to L-asparaginase use as a part of her therapy for acute lymphoblastic leukemia (ALL). She was managed initially with intravenous fluids, bowel rest, nasogastric suctioning, parenteral narcotices, and broad spectrum antibiotics. In addition, within 12 hours of admission to The Children's Hospital (TCH) in Denver, Colorado, she began therapy with octreotide (5 micrograms/kg/day IV divided b.i.d.). With this management, her pseudocyst decompressed without need for surgical intervention, her pancreatitis fully resolved, and she recovered full pancreatic function without any long-term sequelae.

CONCLUSION

Use of octreotide may have served a role in limiting the severity of the disease process in this case. Further studies need to be done to verify its usefulness in this setting.

Renal Cell Carcinomla in Tuberous Sclerosis

Renal cell carcinoma within an angiomyolipoma was diagnosed in a 21-year-old man with tuberous sclerosis. Ultrasound characteristics are discussed. A review of the 21 cases reported since 1969 suggests an increased incidence of renal cell carcinoma in patients with tuberous sclerosis. Genetic studies in humans and animals support this observation. Awareness of predisposition to renal carcinoma is important to help identify this malignancy in patients with tuberous sclerosis and to differentiate carcinoma from other renal lesions that commonly occur in these patients.

Posttraumatic adrenal hemorrhage in children: CT findings in 34 patients

The medical records and CT scans of 34 children with posttraumatic adrenal hemorrhage were reviewed. Adrenal hemorrhage was unilateral in 32 children; most injuries were on the right side. Bilateral hemorrhage was present in two children. The injured gland was oval in 27 cases and triangular in nine. Gland size ranged from 7 to 45 mm long and 4 to 30 mm wide. All adrenal hemorrhages had decreased attenuation relative to liver and spleen on contrast-enhanced CT. Ipsilateral diaphragmatic crural thickening was a frequent (61%) associated finding. Ipsilateral intraabdominal (61%) and intrathoracic (44%) injuries were often present. Clinical signs of adrenocortical insufficiency were not observed in any child. In summary, posttraumatic adrenal hemorrhage is uncommon in children. The hemorrhage is usually unilateral, right sided, and associated with ipsilateral visceral injury.

Posterior fossa intracranial hemorrhage in infants treated with extracorporeal membrane oxygenation: sonographic findings

Posterior fossa hemorrhage was documented by autopsy in five infants who had been treated with extracorporeal membrane oxygenation over a 5-year-period. In all five cases, the diagnosis was made prospectively by cranial sonography. Sonographic findings were compared with those in a control group of 15 infants with normal posterior fossae at autopsy. The following sonographic abnormalities were exhibited in neonates with posterior fossae hemorrhage: loss of definition of the cerebellum and fourth ventricle on midline sagittal images, heterogeneous cerebellar parenchyma, focal hypoechoic lesions, ventricular dilatation, and tentorial abnormalities. Bright foci inferior to the third ventricle were seen in four neonates in the normal control group. These foci measured 5-10 mm in diameter. One cranial sonogram was falsely interpreted as showing a posterior fossa hemorrhage because of prominent echoes in the interpeduncular cistern. Infants treated with extracorporeal membrane oxygenation are at risk for developing posterior fossa hemorrhage. Awareness of sonographic signs and potential pitfalls in the interpretation of posterior fossa hemorrhage is important for early and accurate recognition of these unusual and sometimes treatable hemorrhages.