Outcomes of HLA-mismatched HSCT with TCRαβ/CD19 depletion or post-HSCT cyclophosphamide for inborn errors of immunity

HLA-mismatched transplants with either in vitro depletion of CD3+TCRαβ/CD19 (TCRαβ) cells or in vivo T-cell depletion using post-transplant cyclophosphamide (PTCY) have been increasingly used for patients with inborn errors of immunity (IEI). We performed a retrospective multicenter study via the EBMT registry on 306 children with IEI undergoing first transplant between 2010-2019 from an HLA-mismatched donor using TCRαβ (n=167) or PTCY (n=139). Median age at HSCT was 1.2 years (range, 0.03-19.6 years). The 3-year overall survival (OS) was 78% (95% confidence interval (CI), 71-84%) after TCRαβ and 66% (57-74%) after PTCY (p=0.013). Pre-HSCT morbidity score (hazard ratio (HR) 2.27, 1.07-4.80, p=0.032) and non-Busulfan/Treosulfan conditioning (HR 3.12, 1.98-4.92, p<0.001) were the only independent predictors of unfavorable OS. The 3-year event-free survival (EFS) was 58% (50-66%) after TCRαβ and 57% (48-66%) after PTCY (p=0.804). Cumulative incidence of severe acute GvHD was higher after PTCY (15%, 9-21%) than TCRαβ (6%, 2-9%, p=0.007), with no difference in chronic GvHD (PTCY, 11%, 6-17%; TCRαβ, 7%, 3-11%, p=0.173). The 3-year GvHD-free EFS was 53% (44-61%) after TCRαβ and 41% (32-50%) after PTCY (p=0.080). PTCY had significantly higher rates of veno-occlusive disease (14.4% versus TCRαβ 4.9%, p=0.009), acute kidney injury (12.7% versus 4.6%, p=0.032) and pulmonary complications (38.2% versus 24.1%, p=0.017). Adenoviraemia (18.3% versus PTCY 8.0%, p=0.015), primary graft failure (10%, versus 5%, p=0.048), and second HSCT (17.4% versus 7.9%, p=0.023) were significantly higher in TCRαβ. In conclusion, this study demonstrates that both approaches are suitable options in IEI patients, although characterized by different advantages and outcomes.

Central Nervous System Fungal Infections in Children With Leukemia and Undergoing Hematopoietic Stem Cell Transplantation: A Retrospective Multicenter Study

BACKGROUND

Central nervous system fungal infections (CNSFI) are seen in patients with hematologic malignancies and have high morbidity and mortality. Because of their rarity, there is limited data on CNSFI in children with no established treatment protocols or guidelines.

MATERIALS AND METHODS

In this multicenter retrospective study, 51 pediatric patients with leukemia, 6 of whom had undergone bone marrow transplantation, with proven or probable CNSFI were evaluated. Fungal infections were defined as proven or probable based on European Organisation for Research and Treatment of Cancer criteria. Proven CNSFI was diagnosed by appropriate central nervous system (CNS) imaging or tissue sample findings in combination with positive microbiological results of cerebrospinal fluid. A positive culture, microscopic evidence of hyphae, a positive result of the galactomannan assays are defined as positive microbiological evidence. Probable CNSFI was defined as appropriate CNS imaging findings together with proven or probable invasive fungal infections at another focus without CNS when there is no other explanatory condition. Data was collected by using the questionnaire form (Supplemental Digital Content 1, http://links.lww.com/JPHO/A541 ).

RESULTS

Seventeen patients had proven, 34 patients had probable CNSFI. Headaches and seizures were the most common clinical findings. The median time between the onset of fever and diagnosis was 5 days. The most common fungal agent identified was Aspergillus . Sixteen patients received single-agent, 35 received combination antifungal therapy. Surgery was performed in 23 patients. Twenty-two patients (43%) died, 29 of the CNSFI episodes recovered with a 20% neurological sequelae.

CONCLUSION

CNSFIs should be considered in the differential diagnosis in patients with leukemia and refractory/recurrent fever, headache, neurologicalocular symptoms, and a radiologic-serological evaluation should be performed immediately. Early diagnosis and prompt management, both medical and surgical, are essential for improving clinical outcomes.

Primary immunodeficiencies: HSCT experiences of a single center in Turkey

BACKGROUND

Primary immunodeficiency diseases (PID) are characterized by the occurrence of frequent infections and are caused by many genetic defects. Hematopoietic stem cell transplantation (HSCT) is the only curative treatment option for the majority of PID. As a Pediatric Hematology-Oncology-Immunology Transplantation Unit, we wanted to present our HSCT experience regarding treatment of primary immunodeficiency diseases.

METHODS

58 patients were included in the study between January 2014 and June 2019. We searched 9/10 or 10/10 matched-related donor (MRD) firstly, in the absence of fully matched-related donor. We screened matched unrelated donor (MUD) from donor banks. MRD was used in 24 (41.3%) patients, MUD in 20 (34.4%) patients, and haploidentical donors in 14 (24.1%) patients. Demographic data, HSCT characteristics, and outcome were evaluated. While 16 patients had severe combined immunodeficiency (SCID), the remaining was non-SCID.

RESULTS

Of the 58 patients, 38 were male and 20 were female. Median age at transplantation was 12 months (range: 2.5-172 months). Combined immunodeficiencies consisted 67.2% of patients. Mean follow-up time was 27 months (6 months-5 years). Median neutrophil, lymphocyte, and thrombocyte engraftment days were similar in comparison of both donor type and stem cell source. The most common complication was acute GvHD in 15 (25.8%) patients. In total, five patients (31%) belonging to the SCID group and 10 patients (23.8%) belonging to the non-SCID group died. Our total mortality rate was 15 (25.8%) in all patients.

CONCLUSIONS

We would like to present our HSCT experiences as a pediatric immunology transplantation center. Existing severe infections before transplantation period, BCGitis, and CMV are important issues of transplantation in Turkey. However, the follow-up time is shorter than some studies, our results regarding complications and survival are similar to previous reports.

Are the Anxiety Levels of Pediatric Hematology-Oncology Patients Different From Healthy Peers During the COVID-19 Outbreak?

The COVID-19 outbreak has caused anxiety among children with hematology-oncology disease and their families, as it has in every segment of society. In this study, we aimed to detect the anxiety levels of children with hematologic or oncologic disease and of their parents after the COVID-19 outbreak. The sample consisted of 15 patients 12 to 18 years of age receiving treatment in the Pediatric Hematology and Oncology Unit in Altinbaş University Medical Faculty Bahçelievler Medikalpark Hospital and 33 parents of the same unit patients between 6 and 18 years of age, and their 35 healthy peers and their parents. The State-Trait Anxiety Inventory was applied to participant children and their parents to evaluate their general anxiety and pandemic-related anxiety levels. Children with a hematology-oncology disease and their families were compared with healthy peers and their families. No significant difference was observed for pandemic-related anxiety levels (P>0.05). Both parent groups exhibited higher anxiety levels with regard to the pandemic than did their children (P<0.05). Children with hematology-oncology disease reported significantly higher trait anxiety levels when compared with healthy peers (P=0.01). The families of children who had not received stem cell transplantation had higher state and trait anxiety scores than the families of children who had received the transplantation (P<0.05). Even though they were in the high-risk group, children with a hematology-oncology disease and their families had pandemic-related anxiety levels comparable with those of healthy peers and their families.

Comparison of Hematopoietic Stem Cell Transplantation Results in Patients with β-Thalassemia Major from Three Different Graft Types

Allogeneic hematopoietic stem cell transplantation (HSCT) is the curative therapy for β-thalassemias that induces severe life-threatening complications. The human leukocyte antigen (HLA) registries and umbilical cord blood banks have carried out diligent searches to find matched unrelated donors (MUDs) for about 70.0% of patients from 2000 onwards. The chance of finding a non-sibling fully matched family donors is higher in some ethnic groups in which consanguineous marriages are common. We have studied and compared transplant complications and outcomes in different graft types (sibling, non-sibling family and unrelated). The non-sibling matched family donor (MFD) group consisted of four mothers, three fathers, five cousins, one paternal uncle and one paternal aunt. There was no significant difference in the mean transfused CD34+ cells, engraftment, median days of neutrophil and platelet recovery were achieved (p > 0.05). The distribution of postttransplant complication did not show any significant difference between groups (p > 0.05). In univariate analysis and multivarite analyses, age, gender, Pesaro risk group (I-II vs. III) and ABO incompatibilty demonstrated a significant difference in disease free survival (p < 0.05). Furthermore, in the second step of investigating overall survival (OS), age, gender and Pesaro risk group (I-II vs. III) showed a significant difference (p < 0.05). There was no significant difference in transplant-related mortality (TRM) between groups. Non-sibling related donor transplants are important for populations where consanguineous marriages are common. Transplant groups according to graft type had similar thalassemia-free survival (TFS) and OS when using a treosulfan-based regimen in our study.

Oral and Dental Manifestations of Diamond-Blackfan Anemia: Case Reports

Diamond-Blackfan Anemia (DBA) is a red cell aplasia characterized with physical abnormalities. The incidence of the disease is reported to be five to seven (5-7) cases per million births in Europe and 4-5 per million live births in the UK and Netherlands with equal sex ratio. It was first recognized in 1938 but an exact pathophysiology of the disease has not been described yet. These abnormalities are well known, however, detailed oral and dental conditions related with the disease have not been described previously. We herein presented two cases of DBA together with oral and dental findings. Our study is first to report the gingival status of the patients with a complete investigation of any orthodontic or dental abnormalities in these kind of patients. A careful follow up and preventive therapies should not be missed in these kind of patients. (Eur J Dent 2011;5:344-348)

β globin mutations in Turkish, Northern Iraqi and Albanian patients with β thalassemia major

The mutation detection of β thalassemia is absolutely necessary for molecular diagnosis, as well as any genetic epidemiological study. The β globin gene has 3 exons and 2 introns, involved in β-thalassemic pathogenesis. The study aim of the study is to characterize the spectrum of β globin gene mutations in 136 Turkish, Northern Iraqi and Albanian pediatric β thalassemia major patients. After genomic DNA extraction from venous blood and amplification of the target DNA regions with PCR, genotyping was achieved by Sanger based DNA sequencing. The IVSI-110 G>A mutation was the most frequent allele in the Turkish and Albanian patients. In Northern Iraqi patients IVSI-1 G>A was is the most frequent. There are two mutations are firstly reported for Albania [c.*111 A>G 3’ UTR (rs63751128) and c.113 G>A (p.Trp38Ter, p.W38*) (rs35887507)] with this study. These findings may be of value for genetic counseling, premarital diagnosis, prenatal diagnosis and prevention programs.

Oral and dental manifestations of diamond-blackfan anemia: case reports

Diamond-Blackfan Anemia (DBA) is a red cell aplasia characterized with physical abnormalities. The incidence of the disease is reported to be five to seven (5-7) cases per million births in Europe and 4-5 per million live births in the UK and Netherlands with equal sex ratio. It was first recognized in 1938 but an exact pathophysiology of the disease has not been described yet. These abnormalities are well known, however, detailed oral and dental conditions related with the disease have not been described previously. We herein presented two cases of DBA together with oral and dental findings. Our study is first to report the gingival status of the patients with a complete investigation of any orthodontic or dental abnormalities in these kind of patients. A careful follow up and preventive therapies should not be missed in these kind of patients.

Comparison of the approaches to non-febrile neutropenia developing in children with acute lymphoblastic leukemia

The objectives of this study was to investigate of the influences of high-dose (20 mg/kg/day) methyl prednisolone (HDMP) and granulocyte colony stimulating factor (G-CSF) in shortening the duration of chemotherapy-induced neutropenia encountered in children with ALL receiving maintenance therapy. Sixty-four non-febrile neutropenic attacks developed in 29 patients with ALL receiving St Jude XIII maintenance protocol were evaluated retrospectively. The patients were clinically followed up without drugs for shortening the duration of neutropenia in 21 (32.8%) attacs, while HDMP and G-CSF were administered in 26 (40.6%) and 17 (26.6%) attacks, respectively. After the detection of neutropenia, restoration of neutrophil counts at 2nd or 4th days to the levels that allow resuming the chemotherapy were considered as success. While second day and overall success rates in patients administered HDMP and G-CSF were significantly higher than the patients who were observed clinically. Both second day and overall neutrophil counts were significantly higher in patients administered G-CSF than the other groups. Methyl prednisolone and G-CSF treatments were well-tolerated by the patients. The cost-per neutropenic attack was significantly higher in G-CSF group than of the HDMP group. Especially in patients experiencing frequent neutropenic attacks and hence interruptions of the therapy, one of the myelopoiesis induction therapies can be used to shorten the duration of neutropenia. For this indication short-course HDMP therapy can be considered as an alternative to G-CSF in this patients due to its relatively low cost, amenability to outpatient administration, and well-tolerability by children.

Crimean-Congo hemorrhagic fever: five patients with hemophagocytic syndrome

Three pediatric and two adult Turkish patients with Crimean Congo Hemorrhagic Fever (CCHF) induced hemophagocytic syndrome (HPS) were admitted to Ondokuz Mayis University Hospital, which is in the Middle Black Sea Region of Turkey. All of them had remarkable hemophagocytosis in the bone marrow with severe bleeding symptoms along with the other known clinical and laboratory findings of CCHF. We would like to present these patients and to discuss the pathophysiology and the effect of acquired HPS on the severity of the disease.

Hair selenium status in children with leukemia and lymphoma

Selenium (Se) is a trace element contributing to the structure of antioxidant system that saves cells from reactive oxygen species. Low serum Se levels have been reported in pediatric and adult patients with cancers. On the other hand, hair Se levels, predicting the long-term body Se status, have been reported in only adult patients with cancer. The aim of the study was to investigate the hair Se status in children with newly diagnosed lymphoid malignancies and the relation between malnutrition and Se deficiency. Thirty patients with leukemia (n=17) and lymphoma (n=13), and 25 healthy controls were enrolled to the study. Se was determined with atomic absorption spectrophotometrical method. Hair Se levels of the patients were significantly lower than those of control group [666.96+/-341.46 ng/g vs. 1019.22+/-371.83 ng/g (P<0.001)]. Children with lymphoma had lower Se than the children with acute lymphoblastic leukemia but not statistically significant [547.03+/-283.67 ng/g vs. 758.67+/-361.05 ng/g (P>0.05)]. Malnourished patients (11/30) had lower hair Se levels (483.51+/-235.55 ng/g) than those of the controls (P=0.036), whereas the Se levels of the patients who had no malnutrition (773.17+/-352.92 ng/g) were also lower than those of the controls but not statistically significant (P=0.053). There was no correlation between age, sex, and the hair Se levels. In this study, we found that hair Se levels of the children with leukemia and lymphoma, especially those of malnourished patients, were lower than those of controls. Additional studies are needed to determinate whether low levels of hair Se may play a role in carcinogenesis.

Cerebral thrombosis associated with heterozygous factor V Leiden mutation and high lipoprotein(a) level in a girl with factor XIII deficiency

A 5-year-old girl in whom the diagnosis of inherited factor XIII deficiency was established at the age of 1 day presented with cryptic tonsillitis along with drowsiness and an abrupt occurrence of getting left interior cross eyed. While an intracranial hemorrhage was expected, cerebral imaging studies surprisingly revealed multiple sino venous thrombosis. In prothrombotic screening studies she and her father were both found to be heterozygous for factor V Leiden mutation along with having elevated levels of lipoprotein(a). Low-molecular-weight heparin was started. Ventriculoperitoneal shunt was applied because of persistence of increased intracranial pressure. Thrombosis disappeared and blood flow was normalized by the end of 2 months and the patient was discharged on coumadin therapy as being well. We would like to report this unusual case and to discuss the possible effects of two major genetic prothrombotic risk factors on inherited bleeding tendency or vice versa.

Acquired von Willebrand syndrome in a patient with Ewing sarcoma

Acquired von Willebrand syndrome is a rare bleeding disorder with clinical and laboratory features closely resembling to hereditary von Willebrand disease. The syndrome may accompany various conditions, including malignant disorders, most often with Wilms tumor and adrenal cell carcinoma. In this report, the authors present a patient with AvWS in association with Ewing sarcoma for the first time in the literature. The abnormal bleeding tendency was successfully treated with fresh frozen plasma and did not recur after the first two courses of chemotherapy with clinical improvement.

Serum transferrin receptor levels in beta-thalassemia trait

Increased levels of transferrin receptors (TfR) and soluble TfR (sTfR) are reliable indicators of iron deficiency anemia and conditions with enhanced erythropoietic activity. In this study we measured sTfR levels in the cases of beta-thalassemia trait (betaTT) and IDA to see whether it would be a diagnostic tool for the differentiation of betaTT and IDA. On the other hand STfR levels could give an idea about erythropoietic activity in betaTT. Serum transferrin receptor (sTfR) levels were measured with enzyme immune assay in 37 cases with betaTT, in 26 patients with iron deficiency anemia (IDA), in 17 patients with the coexistence of betaTT with IDA, and in 21 healthy controls. Mean sTfR in betaTT (6.54 +/- 1.88) were statistically higher than in controls (5.09 +/- 0.76) and lower than in IDA (11.46 +/- 5.03) and in IDA coexistence with betaTT (14.44 +/- 5.3, p < 0.05 in each comparison). However, in 17 cases with betaTT sTfR levels showed an overlap between the patients with IDA, and in 15 cases with betaTT it also showed an overlap with controls. The finding of higher sTfR levels in betaTT compared with controls suggested that there was a degree of ineffective hematopoiesis in betaTT. Although sTfR levels in IDA were higher than in betaTT, because of largely overlapping values in both groups, it was not satisfactory to distinguish betaTT from IDA.

Hematologic manifestation of childhood celiac disease

We wanted to describe the hematologic manifestations of celiac disease (CD) in childhood. This study included 22 children with CD in whom the disease remained undiagnosed until they had presented with hematological abnormalities, such as anemia, thrombocytopenia, leukopenia or prolonged prothrombin time (PT) and activated partial thromboplastin time (APTT). Anemia was present alone in 19 (86.3%) patients, and leukopenia coexisted with anemia in 2 (9%) patients. Thrombocytopenia was found alone in 1 (4.5%) patient. Twelve patients had an iron deficiency anemia. Iron deficiency coexisted with zinc and vitamin B(12) deficiency in 3 patients, copper and vitamin B(12) deficiency in two, vitamin B(12) deficiency in two, zinc deficiency in two and one patient had combined iron, zinc, and copper deficiency. Males had significantly lower values of hemoglobin (p < 0.05) and MCV (p < 0.05) compared to the females. In conclusion CD should be included in the differential diagnosis in children who present with anemia, leukopenia, thrombocytopenia or prolonged PT and APTT, especially in geographical areas where the prevalence of the CD is high.

Hemostatic side effects of high-dose methotrexate in childhood acute lymphoblastic leukemia

The purpose of this study is to investigate the hemostatic side effects of HDMTX. Between 2001 and 2002, 20 children with acute lymphoblastic leukemia at the Dr. Sami Ulus Children's Hospital, Department of Pediatric Hematology and Oncology, treated according to the St. Jude ALL XIII protocol were eligible to this study. Methotrexate at a dose of 2 g/m(2) was infused over 24 hours. Coagulation screening studies included prothrombin time (PT), APTT, fibrinogen, fibrin degradation product (D-Dimer), factor II, factor V, factor VII, factor VIII, factor IX, factor X, PC, PS, AT-III determinations before HDMTX therapy (PreT), 1 day after (PostT(1D)), and 1 week after (PostT(1W)) the end of the HDMTX infusion. We found that PT and APTT were prolonged, PC, PS, and AT-III levels were decreased with a slight increase in D-Dimer 1 day after the administration of HDMTX and all of them returned to the normal levels by 7 days. In addition we found that FVII, FIX, FX were significantly decreased 1 day after therapy and normalised by 7 days.

Spontaneous haemothorax: an uncommon presentation of Glanzmann thrombasthenia

Glanzmann thrombasthenia is a rare hereditary qualitative platelet disorder characterized by a lifelong bleeding tendency due to quantitative and qualitative abnormalities of the platelet integrin alpha(IIb)beta3. Common clinical manifestations include purpuric type skin bleeding, prolonged bleeding from minor cuts, epistaxis, gingival bleeding and menorrhagia. Less frequently, gastrointestinal system bleeding may occur. Haemarthrosis, haematuria, intracranial and visceral haemorrhage are very rare symptoms. This study reports a 3-y-old girl with Glanzmann thrombasthenia who presented with life-threatening haemothorax. There was no history of recent trauma or drug usage and no vascular or parenchymal abnormalities to explain the development of haemothorax.

CONCLUSION

To the authors' knowledge this is the first case of Glanzmann thrombasthenia complicated by spontaneous haemothorax.

CMV-induced immune thrombocytopenia and excessive hematogones mimicking an acute B-precursor lymphoblastic leukemia

Hematogones (B-lymphocyte progenitor-precursor cells) are normal bone marrow constituents which are morphologically distinct lymphoid cells with homogeneous, condensed uniform nuclear chromatin and scant cytoplasm. Hematogones can be observed in large numbers in the bone marrow of children with a variety of hematologic and nonhematologic disorders.We present here a 3.5-month-old boy with cytomegalovirus (CMV)-induced immune thrombocytopenia and excessive hematogones in the bone marrow mimicking an acute B-precursor lymphoblastic leukemia. To our knowledge this is the first case of acute CMV infection-induced immune thrombocytopenia with hematogones.

Most reliable indices in differentiation between thalassemia trait and iron deficiency anemia

BACKGROUND

Iron deficiency anemia (IDA) and thalassemia trait (TT) are the most common forms of microcytic anemia. Some discrimination indices calculated from red blood cell indices are defined and used for rapid discrimination between TT and IDA. However, there has been no study carried out in which the validity of all of the defined indices are compared in the same patient groups. Youden's index is the most reliable method by which to measure the validity of a particular technique, because it takes into account both sensitivity and specificity.

METHODS

We calculated eight discrimination indices (Mentzer Index, England and Fraser Index, Srivastava Index, Green and King Index, Shine and Lal Index, red blood cell (RBC) count, red blood cell distribution width and red blood cell blood distribution width index (RDWI)) in 26 patients with IDA and in 37 patients with beta TT (betaTT). We determined the number of correctly identified patients by using each discrimination index. We also calculated sensitivity, specificity, positive and negative predictive value and Youden's index of each discrimination index.

RESULTS

None of the discrimination indices showed a sensitivity and specificity of 100%. Youden's indices of RBC count and RDWI were the highest with the value of 82 and 80%, respectively. Ninety percent and 92% of the patients were correctly identified with RBC and RDWI, respectively.

CONCLUSIONS

Red blood cell count and RDWI are the most reliable discrimination indices in differentiation between betaTT and IDA.

Parvovirus-B19 infection preceding acute myeloid leukemia with orbital granulocytic sarcoma

We report here an unusual presentation of acute nonlymphoblastic leukemia with ocular granulocytic sarcoma who was firstly diagnosed iron deficiency anemia and acute parvovirus infection induced erythroid hypoplasia. To our knowledge this is the first paper of acute myeloblastic leukemia (AML) with granulocytic sarcoma, preceded by acute Parvovirus B19 infection.

Clinical course of children with immune thrombocytopenic purpura treated with intravenous immunoglobulin G or megadose methylprednisolone or observed without therapy

The authors compared the prognosis in 50 children with acute immune thrombocytopenicpurpura (ITP) who received intravenous immunoglobulin G (IVIG), megadose methylprednisolone (MDMP), or no therapy. Twenty-six children were observed with no therapy, 12 children received IVIG, and 12 children received MDMP. The percentage of the patients whose platelet counts increased at a level of > 20 x 10(9)/L and > 50 x 10(9)/L at 3 days after starting therapy was significantly higher in both IVIG and MDMP groups than in the no therapy group (p < .01), but there was no significant difference at 10 and 30 days after initiation between the 3 groups (p > .05 in each comparison). This result suggested that therapy does not increase the rate of recovery but shortens the duration of thrombocytopenia in the first days. Management derision in ITP is made on clinical condition rather than on platelet count and no treatment options is to be preferred even in the face of mucosal bleeding. If the patient has extensive bleeding and the decision is to treat, both IVIG and MDMP are equally effective in providing a safe platelet level early on.