COVID-19 infection in patients with history of pediatric heart transplant in Germany, Austria, and Switzerland

COVID-19 is a heterogenous infection-asymptomatic to fatal. While the course of pediatric COVID-19 infections is usually mild or even asymptomatic, individuals after adult heart transplantation are at high risk of a severe infection. We conducted a retrospective, multicenter survey of 16 pediatric heart transplant centers in Germany, Austria and Switzerland to evaluate the risk of a severe COVID-19 infection after pediatric heart transplantation between 02/2020 and 06/2021. Twenty-six subjects (11 male) with a median age of 9.77 years at time of transplantation and a median of 4.65 years after transplantation suffered from COVID-19 infection. The median age at time of COVID-10 infection was 17.20 years. Fourteen subjects had an asymptomatic COVID-19 infection. The most frequent symptoms were myalgia/fatigue (n = 6), cough (n = 5), rhinitis (n = 5), and loss of taste (n = 5). Only one subject showed dyspnea. Eleven individuals needed therapy in an outpatient setting, four subjects were hospitalized. One person needed oxygen supply, none of the subjects needed non-invasive or invasive mechanical ventilation. No specific signs for graft dysfunction were found by non-invasive testing. In pediatric heart transplant subjects, COVID-19 infection was mostly asymptomatic or mild. There were no SARS-CoV-2 associated myocardial dysfunction in heart transplant individuals.

Characteristics, management, and outcome of pediatric patients with post-transplant lymphoproliferative disease-A 20 years' experience from Austria

BACKGROUND

Management of pediatric post-transplantation lymphoproliferative disorder (PTLD) after hematopoietic stem cell (HSCT) and solid organ transplantation (SOT) is challenging.

AIM

This study of 34 PTLD patients up to 19-years old diagnosed in Austria from 2000 to 2018 aimed at assessing initial characteristics, therapy, response, and outcome as well as prognostic markers of this rare pediatric disease.

METHODS AND RESULTS

A retrospective data analysis was performed. Types of allografts were kidney (n = 12), liver (n = 7), heart (n = 5), hematopoietic stem cells (n = 4), lungs (n = 2), multi-visceral (n = 2), small intestine (n = 1), and vessels (n = 1). Eighteen/34 were classified as monomorphic PTLD, with DLBCL accounting for 15 cases. Polymorphic disease occurred in nine, and non-destructive lesions in six cases. One patient had a non-classifiable PTLD. Thirteen/34 patients are surviving event-free in first remission (non-destructive, n = 4/6; polymorphic, n = 4/9; monomorphic, n = 6/18). Fourteen/34 patients lacked complete response to first-line therapy, of whom seven died. Four/34 patients relapsed, of whom two died. In 3/34 patients, death occurred as a first event. The 5-year overall and event-free survival rates were 64% ± 9% and 35% ± 9% for the whole cohort. Among all parameters analyzed, only malignant disease as the indication for transplantation had a significantly poor influence on survival.

CONCLUSIONS

This study shows PTLD still to be a major cause of mortality following SOT or HSCT in children. A continued understanding of the molecular biology of the disease shall allow to decrease treatment intensity for lower risk patients and to identify patients who may benefit from newer therapy approaches to improve outcome and decrease morbidity.

Right ventricle-to-pulmonary artery shunt related complications after Norwood procedure

OBJECTIVE

The right ventricle-to-pulmonary artery (RV-PA) shunt in the Norwood procedure (NP) for children with hypoplastic left-heart syndrome (HLHS) provides stable early hemodynamics and improves survival in many centers. However, lower pulmonary-to-systemic flow ratio causes early cyanosis and may require earlier second-stage procedure. The aim of the study was to present shunt-related results after NP with RV-PA shunt and our technique of RV-PA shunt construction.

METHODS

Between June 2001 and August 2010, 236 children with HLHS and variants underwent NP with RV-PA shunt, and were operated on by the same surgeon. The medical records were retrospectively reviewed.

RESULTS

To date, 180 children at a mean age of 7.0 ± 1.6 months with a mean weight of 6.4 ± 0.9 kg underwent second-stage procedure. The mean systemic oxygen saturation before stage 2 operation was 74.8 ± 6.6% and mean arterial partial oxygen pressure was 32.8 ± 6.7 mm Hg. These two parameters were significantly lower than after NP (p = 0.029, p < 0.001, respectively). Between stage 1 and 2 operation, three children (1.3%) died due to the shunt obstruction. Four children (1.7%) underwent re-operations due to shunt problems (one of them died), and the other four (1.7%), stent implantation in RV-PA shunt. Two infants (1.1%) developed aneurysm of the right ventricle infundibulum, which was resected during stage 2 without complications. One child required early (before fifth month of age) second-stage procedure due to the shunt obstruction. The patients with right-sided to the neo-aorta course of the RV-PA shunt had significantly more frequent delayed sternal closure after NP than children with left-sided shunt (35.5% vs 14.1%; p = 0.008).

CONCLUSIONS

The RV-PA shunt can be a safe and efficient technique in providing optimal pulmonary blood flow in the children with HLHS after Norwood procedure, performed with minimal rate of complications. In our experience, the use of RV-PA shunt in NP does not require earlier second-stage procedure.

Efficacy over time of LHRH analogs in the treatment of PCa--a prospective analysis using serum testosterone to determine dosing intervals

OBJECTIVES

To examine the duration of serum testosterone and prostate-specific antigen suppression after each dose of a 4-month depot leuprolide acetate for 18 months and to assess the potential for using serum testosterone as a guide for redosing the luteinizing hormone-releasing hormone analogs instead of using fixed dosing intervals. Luteinizing hormone-releasing hormone analogs are well established for the treatment of prostate cancer (PCa). However, many open questions remain regarding the optimal dosing.

METHODS

Thirteen patients with PCa were enrolled in a longitudinal study. Serum testosterone levels were obtained at baseline and then monthly beginning 4 months after the first injection and every 2 months after the subsequent injections, for a total of 18 months. The median number of days from injection to the first serum testosterone level > or = 50 ng/dL was estimated using the Kaplan-Meier product-limit method.

RESULTS

The median duration of effect was 159, 189, and 163 days for the first, second, and third treatment cycle, respectively. The prostate-specific antigen values from entry to completion decreased in all subjects. The total number of injections was reduced in all but one subject who completed the 18-month trial. One patient developed hormone-refractory PCa.

CONCLUSIONS

Serum testosterone measurement might be a useful method for redosing luteinizing hormone-releasing hormone analogs. Using testosterone levels to determine the time of reinjection has a significant economic impact. Monitoring serum testosterone not only helps to identify patients who fail to achieve testosterone suppression but also provides close monitoring for the potential development of hormone-refractory PCa.

Yersinia enterocolitica leads to transient induction of TNF-alpha and activates NF-kappaB in synovial fibroblasts

OBJECTIVE

The importance of the presence of bacterial antigen or even living bacteria for the pathogenesis of reactive arthritis has been discussed increasingly ever since bacterial antigen was found in inflamed joints. Bacteria may persist in the body and drive the local immune response, maintaining arthritis. Cytokines, in particular tumor necrosis factor-alpha (TNF-alpha) are essential for bacterial elimination. In reactive arthritis, the course of the disease is influenced by several cytokines, including TNF-alpha. TNF-alpha expression can be mediated by transcription factor nuclear factor-kappa B (NF-kappaB). Moreover, TNF-alpha is also one of the strongest activators of NF-kappaB.

METHODS

In vitro expression of TNF-alpha and activation of NF-kappaB in synovial fibroblasts after infection with Yersinia enterocolitica or Salmonella enteritidis was analysed by electrophoretic mobility shift assay, Western blot assay and real-time PCR.

RESULTS

We found that infection of synovial fibroblasts with yersinia and salmonellae lead to the transient expression of TNF-alpha mRNA and induction of NF-kappaB.

CONCLUSION

Induction of TNF-alpha in synovial fibroblasts after infection with yersiniae or salmonellae might be insufficient to eliminate bacteria, and this could allow the intracellular persistence of these bacteria. Our results therefore support the hypothesis that a permissive cytokine pattern might contribute to the pathogenesis of reactive arthritis.