Prognostic Factors and Long-term Outcomes in 41 Children With Primary Hemophagocytic Lymphohistiocytosis: Report of a Single-center Experience and Review of the Literature

Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening hyperinflammatory syndrome with diverse clinical manifestations leading to major diagnostic and therapeutic difficulties. This study aimed to evaluate clinical manifestations, prognostic factors, and long-term outcomes in children with primary HLH. Forty-one patients diagnosed with primary HLH were retrospectively evaluated for patient characteristics, HLH gene mutations, clinical and laboratory manifestations, prognostic factors, and long-term outcomes. The median age of the patients at the time of diagnosis was 3 months (minimum to maximum: 1 to 144 mo). There were 23 patients who had HLH mutation analysis performed, 10 patients with PRF1 mutation, 6 with STX11 mutation, and 7 with UNC13D mutation. Thirteen patients (31.7%) had central nervous system involvement. No correlation was found between overall survival and central nervous system involvement. The estimated 5-year overall survival for the patient who had hematopoietic stem cell transplantation was 9.4 times better than the patients who did not receive hematopoietic stem cell transplantation (81.3% vs 16.7%; P = 0.001). Median serum sodium and blood urea nitrogen levels were significantly higher in deceased HLH patients compared with surviving HLH patients ( P = 0.043, and P = 0.017, respectively). Primary HLH has a poor outcome with high mortality, which necessitates well-designed and international clinical trials to improve diagnosis, therapy, and long-term outcomes.

Prognostic factors for survival in children who relapsed after allogeneic hematopoietic stem cell transplantation for acute leukemia

BACKGROUND

Post-transplant relapse has a dismal prognosis in children with acute leukemia undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT). Data on risk factors, treatment options, and outcomes are limited.

PROCEDURE

In this retrospective multicenter study in which a questionnaire was sent to all pediatric transplant centers reporting relapse after allo-HSCT for a cohort of 938 children with acute leukemia, we analyzed 255 children with relapse of acute leukemia after their first allo-HSCT.

RESULTS

The median interval from transplantation to relapse was 180 days, and the median follow-up from relapse to the last follow-up was 1844 days. The 3-year overall survival (OS) rate was 12.0%. The main cause of death was disease progression or subsequent relapse (82.6%). The majority of children received salvage treatment with curative intent without a second HSCT (67.8%), 22.0% of children underwent a second allo-HSCT, and 10.2% received palliative therapy. Isolated extramedullary relapse (hazard ratio (HR): 0.607, P = .011) and relapse earlier than 365 days post-transplantation (HR: 2.101, P < .001 for 0-180 days; HR: 1.522, P = .041 for 181-365 days) were found in multivariate analysis to be significant prognostic factors for outcome. The type of salvage therapy in chemosensitive relapse was identified as a significant prognostic factor for OS.

CONCLUSION

A salvage approach with curative intent may be considered for patients with post-transplant relapse, even if they relapse in the first year post-transplantation. For sustainable remission, a second allo-HSCT may be recommended for patients who achieve complete remission after reinduction treatment.

Role of a second transplantation for children with acute leukemia following posttransplantation relapse: a study by the Turkish Bone Marrow Transplantation Study Group

We examined outcomes of 51 pediatric patients with relapsed acute leukemia (AL) who underwent a second allogeneic hematopoietic stem cell transplantation (alloHSCT). After a median follow-up of 941 days (range, 69-2842 days), leukemia-free survival (LFS) and overall survival (OS) at 3 years were 26.6% and 25.6%, respectively. The nonrelapse mortality rate (NMR) and cumulative incidence of relapse (CIR) were 36.4% and 42.4%, respectively. The Cox regression analysis demonstrated that the risk factors at second transplantation for predicting limited LFS were active disease (hazard ratio (HR) = 5.1), reduced intensity conditioning (RIC) (HR = 5.0), matched unrelated donor (MUD) (HR = 3.4) and performance score <80 (HR = 3.2). Pediatric patients with AL who relapsed after their first alloHSCT may survive with a second alloHSCT. Disease status, conditioning intensity, donor type, and performance score at the second transplantation are the relevant risk factors. A score based on these factors may predict the results of the second transplantation.

Homozygous c.130-131 ins A (pW44X) mutation in the HAX1 gene as the most common cause of congenital neutropenia in Turkey: Report from the Turkish Severe Congenital Neutropenia Registry

BACKGROUND

Severe congenital neutropenia is a rare disease, and autosomal dominantly inherited ELANE mutation is the most frequently observed genetic defect in the registries from North America and Western Europe. However, in eastern countries where consanguineous marriages are common, autosomal recessive forms might be more frequent.

METHOD

Two hundred and sixteen patients with severe congenital neutropenia from 28 different pediatric centers in Turkey were registered.

RESULTS

The most frequently observed mutation was HAX1 mutation (n = 78, 36.1%). A heterozygous ELANE mutation was detected in 29 patients (13.4%) in our cohort. Biallelic mutations of G6PC3 (n = 9, 4.3%), CSF3R (n = 6, 2.9%), and JAGN1 (n = 2, 1%) were also observed. Granulocyte colony-stimulating factor treatment was given to 174 patients (80.6%). Two patients died with infectious complications, and five patients developed myelodysplastic syndrome/acute myeloblastic leukemia. The mean (± mean standard error) follow-up period was 129.7 ± 76.3 months, and overall survival was 96.8% (CI, 94.4-99.1%) at the age of 15 years. In Turkey, severe congenital neutropenia mostly resulted from the p W44X mutation in the HAX1 gene.

CONCLUSION

In Turkey, mutation analysis should be started with HAX1, and if this is negative, ELANE and G6PC3 should be checked. Because of the very high percentage of consanguineous marriage, rare mutations should be tested in patients with a negative mutation screen.

Congenital Factor Deficiencies in Children: A Report of a Single-Center Experience

Congenital factor deficiencies (CFDs) refer to inherited deficiency of coagulation factors in the blood. A total of 481 patients with CFDs, who were diagnosed and followed at our Pediatric Hematology and Oncology Clinic between 1990 and 2015, were retrospectively evaluated. Of the 481 cases, 134 (27.8%) were hemophilia A, 38 (7.9%) were hemophilia B, 57 (11.8%) were von Willebrand disease (vWD), and 252 (52.3%) were rare bleeding disorders (RBDs). The median age of the patients at the time of diagnosis and at the time of the study was 4.1 years (range: 2 months to 20.4 years) and 13.4 years (range: 7 months to 31.3 years), respectively. The median duration of the follow-up time was 6.8 years (range: 2.5 months to 24.8 years). One hundred nineteen (47.2%) of 252 patients with RBDs were asymptomatic, 49 (41.1%) of whom diagnosed by family histories, 65 (54.6%) through preoperative laboratory studies, and 5 (4.2%) after prolonged bleeding during surgeries. Consanguinity rate for the RBDs was 47.2%. Prophylactic treatment was initiated in 80 patients, 58 of whom were hemophilia A, 7 were hemophilia B, 13 were RBDs, and 2 were vWD. Significant advances have been achieved during the past 2 decades in the treatment of patients with CFDs, particularly in patients with hemophilias. The rarity and clinical heterogeneity of RBDs lead to significant diagnostic challenges and improper management. In this regard, multinational collaborative efforts are needed with the hope that can improve the management of patients with RBDs.

Acute Megakaryoblastic Leukemia with t(1;22) Mimicking Neuroblastoma in an Infant

Acute megakaryoblastic leukemia (AMKL) with t(1;22) (p13;q13) is an extremely rare subtype of acute myeloid leukemia that is almost always described in infants. t(1;22) (p13;q13)-positive AMKL with extramedullary infiltration has been previously reported only once in the literature. Herein, we report a 3-month-old infant presenting with a pelvic mass and pancytopenia suggesting neuroblastoma. Bone marrow evaluation revealed t(1;22)-positive AMKL that responded well to a regimen containing high-dose cytarabine.

Is Swine-origin Influenza a Predisposing Factor for Deep Vein Thrombosis?

Herein we report a sixteen-year-old female that developed deep vein thrombosis (DVT) while undergoing treatment for H1N1 pneumonia. To the best of our knowledge this is the first report of H1N1/09 infection complicated by DVT in an adolescent patient with no detected risk factors other than immobilization. Healthcare providers should be aware of the possibility of thrombosis in patients with swine-origin influenza, especially in those with additional risk factors.

A rare metabolic complication of acute lymphoblastic leukemia in childhood: lactic acidosis

A 13-year-old boy presented with nausea, fatigue, weight loss, and bone pain for two months. Complete blood count and serum renal and liver function tests were all normal. Blood gas analysis revealed severe metabolic acidosis with high anion gap. Lactate level was 61.2 mmol/L. Abdominal ultrasonography yielded bilateral nephromegaly and hepatomegaly with increased echogenicity. Peripheral blood smear revealed 2% blasts. Bone marrow aspiration showed 'Common ALL Antigen'-negative acute lymphoblastic leukemia by flow cytometric analysis. Metabolic acidosis dissolved as soon as chemotherapy was begun. Lactic acidosis at the presentation of acute lymphoblastic leukemia--especially with low tumor burden--is a very rare and almost always fatal complication. Our patient is still alive and in remission, which is a point of interest in this child.

An unexpected parasitic cause of hypereosinophilia: fascioliasis

A six-year-old boy from Eastern Anatolia was admitted to our outpatient clinic with abdominal pain and hyperleukocytosis. His leukocyte count was 50 x 10(9)/L with an 80% eosinophilia. Serological investigation was positive at a titration of 1/2560 for Fasciola hepatica. Hepatomegaly with linear hypoechogenic strains, which is typical for F. hepatica, was seen on abdominal ultrasonography. He was successfully treated with triclabendazole, 10 mg/kg/day. He is now under follow-up without any complaints. Hypereosinophilia mimicking leukemia is not an expected finding. To our best knowledge, high leukocyte count with F. hepatica in a child has not been reported in the literature until now.

Hematological consequences of pandemic influenza H1N1 infection: a single center experience

Since its identification in April 2009, pandemic influenza H1N1 virus has affected thousands of people worldwide. Viruses, particularly Epstein-Barr virus, cytomegalovirus and parvovirus B19, may have diverse hematological consequences, including anemia, neutropenia, thrombocytopenia, lymphocytosis, hemophagocytic lymphohistiocytosis, and coagulation abnormalities. In this study, a total of 31 consecutive pediatric patients, with and without chronic diseases, who had flu symptoms and were confirmed to have pandemic influenza, were evaluated for hematological consequences upon presentation to hospital. Eight (25.8%) patients had leukopenia and six (19.4%) had thrombocytopenia at the time of diagnosis of H1N1 infection. Pandemic influenza H1N1 infection may cause diverse hematological findings, including cytopenias and hemophagocytosis.

A comparative ID migraine screener study in ophthalmology, ENT and neurology out-patient clinics

Migraine is more likely to be misdiagnosed in patients with comorbid diseases. Not only primary care physicians, but also specialists might misdiagnose it due to the lack of diagnostic criteria awareness. The ID migraine test is a reliable screening instrument that may facilitate and accelerate migraine recognition. This study aimed to compare the prevalence and characteristics of migraine in a large sample of patients admitted to clinics of ophthalmology (OC), ear, nose and throat diseases (ENTC) and neurology (NC), as well as to validate the use of the ID migraine test in OC and ENTC settings. This was a multicentre (11 cites) study of out-patients admitting either to NC, ENTC or OC of the study sites during five consecutive working days within 1 week. From each of the clinics, 100 patients were planned to be recruited. All recruited patients were interviewed and those having a headache complaint received an ID migraine test and were examined for headache diagnosis by a neurologist, blinded to the ID migraine test result. A total of 2625 subjects were recruited. Only 1.3% of OC patients and 5.4% of ENTC patients have been admitted with a primary complaint of headache, whereas the percentage of NC patients suffering from headache was 37.6%. Whereas 138 patients (19.3%) in OC, 154 (17.3%) in ENTC and 347 (34%) in NC were found to be ID migraine test positive, 149 patients (20.8%) in OC, 142 (16%) in ENTC and 338 (33.1%) in NC were diagnosed with migraine. The sensitivity, specificity, and positive and negative predictive ratios of the ID migraine test were found to be similar in all clinics. An important fraction of the patients admitted to NC, as well as to OC and ENTC, for headache and/or other complaints were found out to have migraine by means of a simple screening test. This study validated the ID migraine test as a sensitive and specific tool in OC and ENTC, encouraging its use as a screening instrument.

The effect of growth hormone treatment on head circumference in growth hormone-deficient children

The aim of this study was to analyze head circumference (HC) growth retrospectively in longitudinally followed growth hormone (GH)-deficient children on GH therapy. Data of 54 (25 F, 29 M) children with GH deficiency were analyzed by dividing the children into two groups: Group 1 with height age (HA) < or =5 years (yrs) (n:18) and Group 2 with HA >5 yrs (n:36). Anthropometric measurements were expressed as standard deviation score (SDS) for chronological age (CA), and HC was also expressed as SDS for CA and HA. Group 1, with CA 6.6 (2.9) yrs at onset of therapy, showed an increase in height SDS from -3.8 (1.4) to -2.4 (1.7) (p < 0.001) and in HC SDS for CA from -1.9 (1.5) to -1.3 (1.6) (p < 0.05) on 4.8 (3.5) yrs of therapy. Group 2, with CA 12.6(2.2) yrs, increased height SDS from -3.4 (1.3) to -2.5 (1.4) (p < 0.001) and HC SDS for CA from -1.2 (1.3) to -1.4(1.2) (NS). HC SDS for HA was -0.4(1.3) in Group 1 and -0.2 (1.1) in Group 2 and showed no significant change. When analyzed by quartiles for cumulative dose of GH, HC SDS for HA became 0.08(1.2) in the fourth dosage quartile (p = 0.043), not significantly different from the mean. HC is disproportionately small for age but normal for the height. GH treatment results in an increase in HC of the children towards normalization in younger children. An increase in cumulative GH dose is associated with an increase in HC, but this is not inappropriate.

Neurologic and cardiac findings in children with Sydenham chorea

This study investigated the association between cardiac and neurologic findings and the long-term prognosis in Sydenham chorea. A retrospective, descriptive study was conducted with 40 patients between 1991 and 2004. Their age, gender, clinical findings, severity of disease, presence of carditis, and neurological findings were evaluated. Patients were predominantly female (70%), and the mean age was 11.3 +/- 2.5 years. The mean duration of chorea was 5.3 +/- 3.1 months (range, 1-12 months). Chorea was mild in 30 patients, moderate in 9, and severe in 1. Carditis was confirmed by echocardiography in 28 cases (70%); the most frequently involved valve was the mitral (35%). Duration of chorea in patients with carditis did not differ significantly from that in patients without carditis. Mean follow-up time was 2.6 +/- 1.5 years. Acute flaring of acute rheumatic fever did not recur in any patient taking penicillin prophylactically. No patient had persistent chorea. Although murmurs in patients with Sydenham chorea predicts carditis with high probability, the absence of murmur does not exclude it. In patients with carditis, the mitral valve is the one most frequently involved.

Synthesis, in vitro cytotoxic and antiviral activity of cis-[Pt(R(–) and S(+)-2-α-hydroxybenzylbenzimidazole)2Cl2] complexes

A pair of enantiomeric platinum(II) complexes of cis-[Pt(R(-) and S(+)-HBB)2Cl2] (HBB=2-alpha-hydroxybenzylbenzimidazole) was synthesized and evaluated for its preliminary in vitro cytotoxic activity on the human MCF-7 breast cancer and HeLa cervix cancer cell lines and antiherpes virus activity against bovine herpesvirus type 1 (BHV-1). In general, it was found that Pt(II) complexes were less cytotoxic on both cell lines than cisplatin and were comparable to carboplatin. There was no significant difference in cytotoxicity between two enantiomers, and the antiviral test results showed that the Pt(II) complexes and their carrier ligands R(-) and S(+) HBB had no effects inhibiting replication of BHV-1.

Synthesis and Analgesic and Antiinflammatory Activity of Methyl 6-Substituted-3(2H)-pyridazinone-2-ylacetate Derivatives

A series of methyl 6-substituted-3(2H)-pyridazinone-2-ylacetates 9 were synthesized and their analgesic and anti-inflammatory effects were evaluated in the phenylbenzoquinone-induced writhing test (PBQ test) and carrageenan-induced paw edema method, respectively. Side effects of the compounds were examined on gastric mucosa. None of the compounds showed gastric ulcerogenic effect compared with reference nonsteroidal anti-inflammatory drugs. Methyl 6-(4-(4-fluorophenyl)piperazine)-3(2H)-pyridazinone-2-ylacetate 9e was found to be more active than acetylsalicylic acid (ASA). Methyl 6-(4-(2-ethoxyphenyl)piperazine)-3(2H)-pyridazinone-2-ylacetate 9c has shown an anti-inflammatory activity as compared to the standard compound indometacin at the carrageenan-induced paw edema method.A significant dependence of the anti-inflammatory effect on the substituents has been observed. The pharmacological study of these compounds confirms that modification of the chemical group at the position 6 of the 3(2H)-pyridazinone system influences analgesic and anti-inflammatory activities. The structures of these new pyridazinone derivatives were confirmed by their IR and (1)H-NMR spectra and elemental analysis.

Congestive heart failure associated with chronic venous insufficiency and leg ulcers secondary to an arteriovenous fistula caused by a shotgun wound 15 years ago

We present a 65-year-old man who had a significant arteriovenous fistula between the right arteria profunda femoralis and vena profunda femoralis. He had evidence of chronic venous insufficiency and chronic leg ulcers on his right leg, and he had clinical findings of congestive heart failure. An arteriovenous fistula was responsible for all of clinical situation that had been caused by a shotgun wound 15 years ago. Using ultrasonography, after palpating a marked thrill and mass during physical examination, established the diagnosis of arteriovenous fistula. Angiography was performed both to delineate the suspected vascular anatomy and to show the coronary arteries. The patient was operated on and no complication was experienced during or after the procedure. Dramatic improvement was seen in the clinical picture just after surgery, and heart size markedly reduced both on chest X-ray and echocardiographic examination.

Echocardiographic evaluation in patients with hypogonadotropic hypogonadism

OBJECTIVE

To assess cardiac function in patients with hypogonadotropic hypogonadism.

STUDY DESIGN

We studied heart structure and left ventricular systolic and diastolic function by echocardiography in 38 patients with hypogonadotropic hypogonadism (34 men and 4 women, mean age 24 +/- 4 years) and in 30 healthy subjects (25 men and 5 women, mean age 22 +/- 3 years). Left ventricular end-diastolic diameter, end-systolic diameter, left ventricular septal wall thickness, posterior wall thickness and ejection fractions were measured by M-mode echocardiography. Parameters of mitral flow were measured by pulsed wave Doppler echocardiography.

RESULTS

Between patients with and without hypogonadotropic hypogonadism, there were no significant differences in echocardiographic measurements.

CONCLUSION

Cardiac function is normal in patients with hypogonadotropic hypogonadism.

Marfan's syndrome, dextrocardia and situs inversus associated with discrete subaortic stenosis and aortic insufficiency in an adult female: case report

Marfan's syndrome is an inherited connective tissue defect that affects many organs, especially of the musculoskeletal, ophthalmic and cardiovascular systems, and may be associated with some rare conditions. Here, we report the first known case of Marfan's syndrome, combined with situs inversus totalis with dextrocardia and discrete subaortic stenosis and aortic insufficiency in a 22-year-old woman.

A coronary aneurysm complicated by acute myocardial infarction. A case report

Coronary artery aneurysm (CAA) is a relatively rare disease that may cause angina, myocardial infarction, sudden death due to thrombosis, embolisation, or rupture. This report describes the case of a man aged 65 years old who had an anterior myocardial infarction due to left anterior descending artery (LAD) aneurysm. We attempted early percutaneous transluminal coronary angioplasty (PTCA) for treatment of acute myocardial infarction, but were not successful. He was then treated with intracoronary streptokinase. Serial coronary angiographies showed recanalisation and aneurysm on the LAD. The patient was operated on with coronary bypass surgery, and treated with an oral anticoagulant, nitrate, and blocker. He was well after one year of follow-up.

Rupture of the right sinus of valsalva into the right ventricle: echocardiographic and angiographic imaging

We report a 16-year-old girl with acute rupture of the sinus of Valsalva. This case is unique in that the right coronary sinus of Valsalva ruptured into both the right and left ventricles, producing severe aortic insufficiency. The diagnosis was made with two-dimensional and color Doppler echocardiography which showed an abnormal jet flow from the aortic root into both ventricles. The diagnosis was confirmed by magnetic resonance imaging and aortic root angiography. Early diagnosis is important so that urgent surgical treatment can be taken.

Two-dimensional color doppler echocardiographic imaging of a Gerbode defect: a case report

A Gerbode defect is a ventricular septal defect that communicates directly between the left ventricle and the right atrium. The pathology may be due to a congenital defect, can result from trauma, or can occur after endocarditis or aortic valve replacement. We report the case of a 20-year-old man who has a defect between the left ventricle and the right atrium (Gerbode defect) that was diagnosed with two-dimensional color Doppler echocardiography.

Amiodarone pigmentation, eye and thyroid alterations

Amiodarone is an effective cardiac antiarytmic drug. Long-term, high dose use of the drug is associated with skin discolouration, corneal deposition and alterations in thyroid hormone levels. We present the case of a 61-year-old woman suffering from the combination of these three side-effects.

A novel MMC-loaded pHEMA drainage device for the treatment of glaucoma: in vitro and in vivo studies

Administration of subconjunctival 5-fluorouracil (5-FU) and topical mitomycin-C (MMC) has been shown to improve the success rate of glaucoma-filtering surgery. However, corneal toxicity and administrative problems remain. To overcome this limitation, drainage devices for the sustained release of 5-FU and MMC were designed and tested in vitro and in vivo. This paper presents only the results of our studies which were carried out on MMC-loaded devices. Here, the drainage devices were prepared from MMC-loaded poly(hydroxyethyl methacrylate) (pHEMA) matrices in different cross-linking ratios and in different drug loading capacities, i.e. 0.2, 0.5, and 2.0 mg MMC per device. These devices released MMC at approximately 6.0-90.0 micrograms day-1 for over 2 months depending on cross-linking density and initial drug loading. The diffusional release of MMC from glassy and swollen copolymers showed that diffusion mechanism is Fickian in both cases. The usability of the pHEMA implants were investigated by in vivo experiments which were done on eight dog's eye. In the treatment eyes, intraocular pressures remained significantly lower than the control eyes throughout the experimental period (4 months). Subconjunctival implantations revealed no clinical and histological evidence for toxicity. The results of in vitro and in vivo studies indicate that an implantable release system delivering MMC for over 2 months can improve the prognosis for filtering surgery by preventing postoperative fibrosis.