EBV-driven lymphoid neoplasms associated with pediatric ALL maintenance therapy

The development of a second malignancy after the diagnosis of childhood acute lymphoblastic leukemia (ALL) is a rare event. Certain second malignancies have been linked with specific elements of leukemia therapy, yet the etiology of most second neoplasms remains obscure and their optimal management strategies are unclear. This is a first comprehensive report of non-Hodgkin lymphomas (NHLs) following pediatric ALL therapy, excluding stem-cell transplantation. We analyzed data of patients who developed NHL following ALL diagnosis and were enrolled in 12 collaborative pediatric ALL trials between 1980-2018. Eighty-five patients developed NHL, with mature B-cell lymphoproliferations as the dominant subtype (56 of 85 cases). Forty-six of these 56 cases (82%) occurred during or within 6 months of maintenance therapy. The majority exhibited histopathological characteristics associated with immunodeficiency (65%), predominantly evidence of Epstein-Barr virus-driven lymphoproliferation. We investigated 66 cases of post-ALL immunodeficiency-associated lymphoid neoplasms, 52 from our study and 14 additional cases from a literature search. With a median follow-up of 4.9 years, the 5-year overall survival for the 66 patients with immunodeficiency-associated lymphoid neoplasms was 67.4% (95% confidence interval [CI], 56-81). Five-year cumulative risks of lymphoid neoplasm- and leukemia-related mortality were 20% (95% CI, 10.2-30) and 12.4% (95% CI, 2.7-22), respectively. Concurrent hemophagocytic lymphohistiocytosis was associated with increased mortality (hazard ratio, 7.32; 95% CI, 1.62-32.98; P = .01). A large proportion of post-ALL lymphoid neoplasms are associated with an immunodeficient state, likely precipitated by ALL maintenance therapy. Awareness of this underrecognized entity and pertinent diagnostic tests are crucial for early diagnosis and optimal therapy.

Pediatric Undifferentiated Pleomorphic Sarcoma of the Cecum

Background: Undifferentiated pleomorphic sarcoma (UPS) is a high-grade neoplasm typically diagnosed in older adults and localized to the extremities or retroperitoneum. Because of poor response to therapy and high rates of recurrence, this neoplasm is associated with a poor prognosis. Case Report: A 12-year-old female presented with weight loss, abdominal pain, fatigue, and diarrhea. She was profoundly anemic with occult blood-positive stools. On endoscopy, a fungating cecal mass was biopsied and diagnosed as malignant sarcomatoid neoplasm. The neoplasm was resected with clear margins during subsequent surgery, and on final pathology was diagnosed as UPS. A suspicious lung nodule was also removed via video-assisted thoracoscopic surgery and found to be a granuloma positive for Histoplasma capsulatum for which the patient received antifungal therapy. The patient did not receive additional chemotherapy or radiotherapy and was doing well without signs of recurrence at 12 months postresection. Conclusion: This report of cecal UPS in a 12-year-old is rare because of the patient's age and tumor location. We have identified only 2 other case reports of pediatric gastrointestinal UPS. This case illustrates the need for a broad differential and prompt workup in pediatric patients presenting with weight loss and abdominal complaints. More information regarding the management and outcomes in cases of gastrointestinal UPS is needed to assist providers in determining the best treatment course and to allow for better prognostication.

Prevalence and Resolution of Lupus Anticoagulant in Children

BACKGROUND

Lupus anticoagulant (LA) is an autoantibody that inhibits phospholipid-dependent reactions. Studies on the incidence and prevalence of LA in the pediatric population are lacking. The objective of our study was to determine the incidence and potential risk of complications of LA in children presenting with abnormal partial thromboplastin time (PTT). Our secondary objective was to identify signs, symptoms, and medical history associated with the presence of LA as documented in the literature. We focused on the correlation between signs of LA in the form of laboratory values consistent with bleeding abnormalities and the presence of clinical symptoms of bleeding.

METHODS

We conducted a record-based retrospective analysis of 112 children and adolescents referred to the Department of Hematology/Oncology at Children's Hospital of New Orleans for abnormal coagulation profiles and/or history of mucocutaneous bleeding. Participants were followed up until PTT values normalized.

RESULTS

In our study population with suspected bleeding disorder, the preliminary incidence of LA was 21%. We found that resolution of LA correlated with correction of PTT in 90% of patients.

CONCLUSION

To minimize extensive and expensive blood workup, we recommend that screening for LA be included in the evaluation of children with prolonged PTT, even if they have a negative history of bleeding problems.

Cisplatin and cranial irradiation-related hearing loss in children

BACKGROUND

High doses of cisplatin and cranial radiotherapy (CRT) have been reported to cause irreversible hearing loss. The objective of this study was to examine the influence of cranial irradiation on cisplatin-associated ototoxicity in children with pediatric malignancies.

METHODS

Serial audiograms were obtained for 33 children, age <16 years, treated with cisplatin-based chemotherapy (90-120 mg/m(2) per cycle) with or without CRT. Eligible patients included those with normal baseline audiometric evaluations and without significant exposure to other ototoxic drugs. We defined significant hearing loss as a hearing threshold ≥30 dB at 2,000-8,000 Hz frequencies.

RESULTS

The median age of our study population was 4.9 years (range 6 weeks to 16 years), and the male to female ratio was 0.8:1. The study population consisted of 15 Caucasians, 17 African-Americans, and 1 Hispanic. Fourteen patients had brain tumors, and 19 had other solid tumors. Thirteen patients were exposed to CRT, and 20 were not. Bilateral hearing loss was observed in 24/33 (73%) patients, with severe/profound (≥70 dB) impairment in 10/33 (30%) of all patients. Young age (<5 years), CRT, and brain tumors were independent prognostic factors predicting hearing loss.

CONCLUSION

The study demonstrated a high incidence of hearing loss in children treated with cisplatin and CRT. Consequently, we recommend monitoring these children for the early detection of hearing loss.

Management of immune thrombocytopenic purpura: an update

Rapid strides have been made in the field of hematology, and advances in immune thrombocytopenic purpura (ITP) management are no exception. From idiopathic to immune, the changed nomenclature is itself a testimonial to the growing awareness and improvements in the management of ITP. We discuss the pathophysiology, clinical presentation, and current management of this common pediatric disorder and summarize current guidelines for ITP treatment.

Increased circulating levels of soluble HLA class I heterodimers in patients with sickle cell disease

This study examined the presence of a persistent state of low-grade inflammation in sickle cell anemia patients by measuring circulating sHLA-I heterodimers and C-reactive protein during the steady state and after recent crises. Thirty-nine pediatric sickle hemoglobinopathy patients were studied during the steady state and 11 patients were evaluated within 1 month of a painful crisis. A disease severity score was generated for each patient, and soluble HLA-I (sHLA-I) and C-reactive protein levels were determined. Soluble HLA-I was significantly elevated in 55% of the steady-state group and in 36% of the recent-crisis group. The percentage of patients with elevated sHLA-I differed in the various disease subgroups in the steady state: 46% of Hb SS patients, 70% of Hb SC patients, 75% of Hb S beta-thal patients, and 20% of Hb SSF patients. Steady-state and recent-crisis sHLA-I levels were not significantly different. C-reactive protein levels were elevated in 11% of steady-state patients and in 9% of recent-crisis patients. Soluble HLA-I levels did not correlate with C-reactive protein levels or disease severity score, age, hemoglobin, reticulocyte count, platelet count, or white cell count. These results show that the majority of sickle hemoglobinopathy patients have elevated sHLA-I levels during the steady state and after recent crisis, suggesting the presence of chronic inflammation during the steady state.

Poland's syndrome and Wilms tumor: an unusual association

Poland's syndrome, a rare congenital disorder with pectoralis muscular girdle defect, have been reported in association with lymphoreticular malignancies in the past. Childhood solid tumors in association with this congenital anomaly have not been reported so far. We describe this rare association of Poland's syndrome and Wilms tumor. Due to the possibility of increased risk of leukemogenesis in patients with Poland's syndrome, chemo-radiation therapy of Wilms tumor in our patient may increase the risk of secondary leukemia. Therapeutic modification of primary cancer in these patients may be necessary with careful long-term follow-up for early detection and treatment of secondary cancer.

IL-12-deficient mice are defective but not devoid of type 1 cytokine responses

Interleukin-12 (IL-12) has been described as a pivotal molecule in the immune response based in part on its ability to influence the differentiation of T helper (Th) cells into a type 1 (Th1) phenotype. This event is crucial in that appropriate differentiation of naive T cells can determine susceptibility or resistance to given pathogens by influencing the balance between cellular and humoral immunity. In order to further delineate the role of IL-12 in the immune response, we generated mice deficient for this cytokine. IL-12 knockout mice were viable, fully fertile, and displayed no obvious developmental abnormalities. Upon immunological analysis, these mice demonstrated an impaired ability to effect a Th1 response as well as an impaired ability to produce interferon-gamma in response to endotoxin in vivo. These data establish an essential role for IL-12 in the generation of optimal Th1 responses in vivo, but weak responses can occur independently of IL-12.

Colonization with antibiotic-resistant Streptococcus pneumoniae in children with sickle cell disease

OBJECTIVE

Because of susceptibility to severe pneumococcal infection, children with sickle cell disease (SCD) routinely receive penicillin prophylaxis. Increasing rates of penicillin resistance have been reported throughout the world. Our objective was to assess the prevalence of nasopharyngeal colonization with Streptococcus pneumoniae and to assess the antimicrobial susceptibility of the organisms in children with SCD.

STUDY DESIGN

Nasopharyngeal cultures for S. pneumoniae were obtained from all children with SCD attending clinics in a statewide university-based network. Background colonization rates were determined in children attending day care centers in some of the same locations. All recovered S. pneumoniae organisms were tested for susceptibility to penicillin, and all resistant strains were examined for susceptibility to other antibiotics.

RESULTS

Overall nasopharyngeal pneumococcal colonization rates among children with SCD were 12%. Colonization was associated with age less than 2 years (p <0.001) and day care attendance for more than 20 hr/wk (p = 0.00005). More than half of these strains (62%) were resistant to penicillin, 33% having intermediate resistance (minimal inhibitory concentration 0.06 to 1 microgram/ml) and 29%, high level resistance (minimal inhibitory concentration > or = 2.0 microgram/ml). Penicillin resistance was associated with penicillin prophylaxis (p <0.01). Many of these organisms were also resistant to other classes of antibiotics.

CONCLUSIONS

Although penicillin prophylaxis and pneumococcal vaccine for patients with SCD have reduced overall nasopharyngeal colonization and disease caused by S. pneumoniae (p <0.001), a higher percentage of colonizing strains are now resistant both to penicillin and to other antimicrobial agents (p <0.01). Newer strategies for preventing disease and early management of suspected pneumococcal infection in these children must be developed.

Triosephosphate isomerase deficiency: repetitive occurrence of point mutation in amino acid 104 in multiple apparently unrelated families

The molecular basis of triosephosphate isomerase (TPI) deficiency was studied in 3 patients from three separate families. In all 3 patients, genomic DNA directly sequenced after amplification by the polymerase chain reaction exhibited the point mutation TPI315C amino acid 104 Glu-->Asp. Although other mutations known to cause TPI deficiency have been restricted to single families, the amino acid 104 defect has now been described in nine apparently unrelated families throughout the world and is clearly the most frequently occurring form of the disorder. The basis of the repetitive occurrence of this mutation remains unexplained.

The efficacy of ticarcillin-clavulanate and gentamicin as empiric treatment for febrile neutropenic pediatric patients with cancer

The therapeutic efficacy of ticarcillin-clavulanate and gentamicin was assessed in 56 pediatric cancer patients with 95 febrile neutropenic episodes. The mean temperature of these children on admission was 102 degrees F (range 101 degrees to 106 degrees F), with a median absolute neutrophil count of 60. The median hospital stay was 7 days. All of the patients had one of two types of permanent central lines (Port-A-Cath, N = 75; Hickman, N = 20). Of 20 episodes of bacteremia, 17 had microbial isolates that were gram-positive bacteria and 8 of these episodes required the addition of vancomycin. Clinical cure was achieved in 84 of the 95 febrile episodes (88%) with the use of ticarcillin-clavulanate and gentamicin. There were no fatalities, nor were there any major toxicities. We conclude that the combination of ticarcillin-clavulanate and gentamicin is an effective initial empirical therapy for febrile neutropenic children with cancer. Gram-positive pathogens are the usual cause of breakthrough bacteremia in this clinical setting of central line usage, and associated morbidity and mortality from these organisms are low.

Iron status and intake of older infants fed formula vs cow milk with cereal

One hundred four infants were randomly assigned to receive whole cow milk plus iron-fortified cereal (WCM + C) in accord with the previous recommendations of the Committee of Nutrition/American Academy of Pediatrics (CON/AAP); one of two iron-fortified, follow-up formulas; or an iron-fortified infant formula. Mean iron intakes and vitamin C exceeded the recommended dietary allowance in all groups. By 12 mo of age, mean ferritin and mean corpuscular volume were lower in the WCM + C group and significantly more infants had serum ferritin concentrations < 12 micrograms/L. We conclude that infants 6-12 mo of age fed whole cow milk and iron-containing table food are at risk of developing depleted iron stores but not anemia. The iron insufficiency in these infants is not due to inadequate intake of iron or vitamin C, but probably to relatively poor bioavailability of iron in infant cereal.

Isolated CNS involvement in Ewing's sarcoma

Ewing's sarcoma, an uncommon malignant neoplasm of bone, represents about 10% of all the malignant primary bone tumors. The assumption that subclinical metastases are already present in patients with apparently localized tumor indicates the need for systemic therapy as an integral part of primary treatment. The usual sites of metastases are the lungs and skeletal system. Central nervous system (CNS) involvement is rare and is usually seen only in disseminated and fairly advanced disease. We report two patients in whom, after aggressive adjuvant chemotherapy, disease developed in the CNS without local recurrence. In one patient, meningeal involvement with malignant cells was identifiable in the cerebrospinal fluid; in the second patient, who presented with a space-occupying lesion, a diagnosis of arachnoid involvement was made histologically.

An unusual embryonal tumor of the nasal cavity in a neonate--a nasal blastoma? A clinical, histologic, and ultrastructural study

We report the clinicopathological and ultrastructural features of a primitive embryonal tumor which occurred as a polypoid mass in the nasal cavity of a newborn infant. Its primitive-appearing, glycogen-rich, small round cells exhibited epithelial characteristics histologically, immunohistochemically, and ultrastructurally. The tumor was initially diagnosed as embryonal carcinoma because of evidence for endodermal differentiation and lack of specific features of other types of small round cell tumors of childhood. However, it did not have the characteristic features of endodermal sinus tumor nor the anaplasia of the adult type of embryonal carcinoma. It had some resemblance to embryonic somatic tissues and the blastemal component of some of the primitive tumors of childhood. Because of its unique morphological appearance, which has never been reported, and its relatively indolent behavior after chemotherapy and radiotherapy, we believe that this is a distinctive primitive teratoid tumor which may be classified as nasal blastoma.

Transient suppression of F-plasmid incompatibility in a strain of Escherichia coli

The incompatibility between F plasmids is transiently suppressed in Escherichia coli strain CSH54. As a result this strain is able to maintain two F' factors or an F' factor and a mini-F plasmid for considerably longer periods than normal strains. When selective pressure for two markers carried by two separate F's (or an F' and mini-F) is imposed on normal strains, the two plasmids tend to form a cointegrate structure which can be detected genetically by the joint transfer of both the markers upon mating. This does not happen in CSH54; instead, the two plasmids are maintained and transferred independently. Physical evidence for the maintenance of an F' and a mini-F plasmid is provided by agarose gel electrophoresis.

Congenital testicular juvenile granulosa cell tumor in a neonate with X/XY mosaicism

A congenital sex cord-stromal tumor of the testis with morphologic features of juvenile granulosa cell tumor is reported. The tumor occurred in an abdominal testis of a newborn infant with an X/XY karyotype and ambiguous genitalia and presented as a partially cystic mass associated with ascites. Histologically the tumor was comprised of an admixture of solid, cellular, poorly differentiated lobules mimicking graafian follicles. Residual hypoplastic testicular tissue was present at the periphery. This is the 19th reported case of testicular juvenile granulosa cell tumor and the fourth with an underlying sex chromosome anomaly, further emphasizing the relationship of this uncommon neoplasm to abnormal sexual or gonadal development.