Fulminant childhood hemophagocytic syndrome mimicking histiocytic medullary reticulosis. An atypical form of Epstein-Barr virus infection

Ten cases of pediatric fulminant hemophagocytic syndrome, encountered between 1986 and 1989, are described. They occurred in the summer, and the patients presented with fever, jaundice, hepatosplenomegaly, pancytopenia, coagulopathy, and abnormal liver function. Bone marrow studies revealed infiltration by atypical T-lymphoid cells, rare B immunoblasts, and mature histiocytes with hemophagocytosis. Initially, histiocytic medullary reticulosis was suspected in six cases. The clinical course was characterized by rapid deterioration, with a mean period of 16 days from onset of fever to death. The main causes of death were coagulopathy with multiple organ failure and opportunistic infection. In seven of eight cases studied by serologic assay and Southern blot hybridization, acute or active Epstein-Barr virus (EBV) infection was documented. It is suggested that an atypical or fulminant form of primary EBV infection distinct from classic infectious mononucleosis was prevalent in previously healthy children in Taiwan. Younger age involvement and seasonal clustering were characteristic of the disorder described.

The spectrum of beta-thalassemia mutations in Taiwan: identification of a novel frameshift mutation

Seventy-four beta-thalassemia genes from 37 unrelated beta-thalassemia-major patients were systematically characterized by using PCR, dot-blot hybridization, and direct sequencing of amplified genomic DNA. We found that six mutations--namely, II-654, 41/42, -28, 17 beta, -29, and 27/28--were prevalent, accounting, respectively, for 45.9%, 28.4%, 10.8%, 10.8%, 1.4%, and 2.7% of studied patients. The 27/28 mutation has at codon 27-28 a cytosine insertion which has never been reported before. These results indicate that four oligo-probes (II-654, 41/42, -28, and 17 beta) allow allele-mutant determination by oligonucleotide analysis in 95.9% of this group of patients, and direct sequencing can be carried out for other samples. These data will facilitate the prenatal diagnosis of this disease by DNA analysis in Taiwan.

A subset of acute lymphoblastic leukemia with co-expression of myeloid antigens: prevalence and clinical significance

In order to evaluate the biological features and clinical significance of myeloid antigen expression in acute lymphoblastic leukemia (ALL), immunophenotype analysis was performed on leukemic cells from 160 patients diagnosed as ALL by the French, American and British (FAB) criteria using a comprehensive panel of monoclonal antibodies to lymphoid and myeloid associated antigens. Expression of myeloid antigens was found in 32 cases (20%), including 11 out of 49 adults (22.4%) and 21 out of 111 children (18.9%). CD33 was positive in 18 patients (11.3% of the total cases), CD13 in 15 patients (9.4%), CD 11b in 12 patients (7.5%) and CD14 in 1 patient (0.6%). Nine patients expressed two or more myeloid antigens. There were no significant differences in clinical manifestations and hematological pictures between the ALL patients with myeloid antigen expression (My+ ALL) and those without (My- ALL). No consistent chromosomal abnormality was found in My+ ALL. Eighty percent of the childhood and 44.4% of the adult My+ ALL patients achieved complete remission, compared with 87% and 80%, respectively, for childhood and adult My- ALL, but the differences were not statistically significant. After a median follow-up of 2.1 years, there were also no statistically significant associations between myeloid antigen expression and shorter duration of remission or poorer survival rate for patients with both adult and childhood ALL.

The basic isoelectric form of alpha-L-fucosidase from the hepatopancreas of the shrimp Penaeus monodon (Crustacea: Decapoda)

1. alpha-L-Fucosidase was purified ca 10,889-fold to homogeneity from Penaeus monodon, with a final spec. act. of 31,250 U/mg of protein. 2. By using SDS-polyacrylamide gel electrophoresis, the monomers of shrimp alpha-L-fucosidase were discovered to have mol. wts of 63,000 and those of human placental enzyme, 46,000 and 20,000. Since the active shrimp alpha-L-fucosidase was found to have a mol. wt of 233,000 by Superose 12 FPLC, it was concluded that the purified shrimp enzyme was tetrameric. 3. In contrast to the discovery of thermolability with human placental alpha-L-fucosidase, the shrimp enzyme was found to be stable to heating at 65 degrees C for 10 min. 4. The shrimp alpha-L-fucosidase has an isoelectric point (pI) of 8.5, but the human placental enzyme has a pI of 4.0. The shrimp enzyme was sialyated. 5. The shrimp alpha-L-fucosidase has a pH optimum at 5.5 and its Km was 22.2 microM with 4-methyl-umbelliferyl-alpha-L-fucopyranoside as substrate. The human enzyme has a broad pH optimum between 5.0 and 6.5.

Clinical observation of Wilms' tumor

Forty-two cases with Wilms' tumor encountered in the National Taiwan University Hospital from 1978 through 1989 were retrospectively reviewed. Included were 19 boys and 23 girls, with an age range at diagnosis from 7 days to 10 years; a majority were in the first 6 years of life. The presenting symptoms and signs included: abdominal mass (89.2%), hypertension (57.9%), hematuria (28.2%), gastrointestinal symptoms (26.3%), fever (24.3%), and body weight loss (21.6%). The initial laterality of tumor was 28 right and 14 left, with one contralateral and one ipsilateral relapse. One extrarenal Wilms' tumor (right inguinal lymph nodes) was encountered. Every case was confirmed by pathology. Histologic findings included typical Wilms' tumor (35/42), rhabdoid (3/42), anaplastic (3/42), and clear cell (1/42) types. The common sites of metastasis were lung, liver and bone. Major complications during or following therapy were severe pancytopenia, ileus, sepsis or pneumonia, delayed wound healing and tumor rupture with hemorrhage. Rare complications included irradiation hepatitis (venooclusive disease) and colitis. There were 20 deaths. The causes of death were respiratory or hepatic failure due to tumor metastasis, sepsis and internal hemorrhage. Mortality (19/20) usually occurred within two years after diagnosis and therapy. The two-year's relapse-free survival and two-year's survival rates were 51.2% and 53.7%, respectively.

Primary myelofibrosis in children: report of 4 cases

From 1982 to 1985, four cases of primary myelofibrosis were diagnosed in our department. Three were boys and one was a girl. Their ages ranged from 7 months to 15 years. The diagnosis was made based on anemia, leukoerythroblastic change and presence of giant platelets in the peripheral blood, and a bone marrow biopsy showing myelofibrosis. Most of them had anemia, fever, and hepatosplenomegaly on admission. The anemia was severe and refractory to repeated transfusions and steroid therapy in 3 out of the 4 cases. Splenectomy was performed in 1 case, but without satisfactory results. The clinical course and blood pictures in one case resembled leukemia of megakaryocyte lineage (M7), but results of marker studies of the blast cells ruled out the possibility of M7. Three of them underwent leukemic transformation within 2 years and died soon after. The other one died of sepsis 2 weeks after diagnosis. Myelofibrosis in childhood occurs rarely, however, when it does, it always runs a rapid and fatal course.

Infant leukemia: an analysis of nine Chinese patients

A study was made of the cellular and molecular characteristics of nine Chinese infants, consecutively presenting with acute leukemia. Five cases were acute lymphoblastic leukemia (ALL); four were acute nonlymphoblastic leukemia (ANLL). Hyperleukocytosis, hepatosplenomegaly, and poor response to conventional therapy were common features, and CNS involvement was detected at diagnosis in three cases. The blast cells from all five cases with ALL expressed early B-cell markers, i.e., HLA-DR+, CD19+, but CD10-. Terminal deoxynucleotidyl transferase (TdT) was present in blasts from four of the five cases and periodic acid-Schiff staining in blasts from two patients only. The leukemic cells of one patient also showed positive nonspecific esterase activity and expressed myeloid-associated antigens CD33 (My9), CD11 (OkM1), and CD14 (My4 and Mo2). Molecular analysis of leukemic cell DNA from this and two other patients showed rearrangement of the immunoglobulin (Ig) heavy-chain genes, but without any evidence of kappa light-chain gene rearrangement. T-cell receptor (TCR) genes remained in the germline configuration in these cases. Cytogenetic analysis showed translocation t(4;11) (q21;q23) in all four cases studied. In the group of ANLL, three cases belonged to the M4 and one to the M2 subtype. Chromosomal abnormality involving 11q23 was also detected in two patients: t(11;17)(q23;q11) and del(11)(q14q23) in each case respectively. Neither Ig nor TCR gene rearrangement was present in blast cells from patients with ANLL. The data indicate that chromosomal rearrangement of band 11q23 was quite common in Chinese infants with either form of leukemia, a finding that may have pathogenetic implications.

Post-hepatitic aplastic anaemia in children in Taiwan, a hepatitis prevalent area

Aplastic anaemia is a rare but serious complication of hepatitis, and hepatitis is an unusual cause of aplastic anaemia in children in the West. However, the relative frequencies of acquired aplastic anaemia in children in Taiwan, a hepatitis prevalent area, differ from those in the West, in the very high frequency of post-hepatitic aplastic anaemia (23.9% of all cases of aplastic anaemia). This may account for the higher incidence of aplastic anaemia in children in Taiwan. Although the prognosis of post-hepatitic severe aplastic anaemia was very poor, the present study using bone marrow transplantation, antithymocyte (or antilymphocyte) globulin, high-dose methylprednisolone and cyclosporin, etc., has improved the response rate and the survival.

Acute abdomen in childhood leukemia

With the continuing advancement in the treatment of childhood leukemia and the lengthened survival of these patients, an increased incidence of abdominal complications has been observed. A retrospective analysis of 364 patients with leukemia treated at the National Taiwan University Hospital from January 1977 through April 1988 was undertaken. Eleven patients (3.0%) developed abdominal complications during their course of disease, including acute appendicitis, intussusception, intestinal perforation, ovarian cyst rupture, etc. All of these patients had abdominal complications during the initial presentation or relapse of leukemia, and 9 (82%) of them had just received chemotherapy. Ten patients (91%) had thrombocytopenia and 7 (64%) had leukopenia. Blood cultures were positive in 5 patients (45%), and gram-negative enteric bacilli were isolated in 4 of them. All 5 septicemic patients had leukopenia or neutropenia. The clinical manifestations were nonspecific and were often masked. Most of the complications occurred in the right lower abdominal structures. Of the 7 children treated surgically, 3 had long term survival. Among the 4 patients who did not receive an operation, only 1 survived for more than 4 weeks. The mean length of survival tended to be longer in patients with additional surgical treatment. Prompt diagnosis and early aggressive treatment, under modern supportive facilities, appear to offer a more favorable outcome.

An analysis of risk factor and survival in childhood acute lymphoblastic leukemia

To study the survival and prognostic factor of childhood acute lymphoblastic leukemia, 78 newly-diagnosed cases between January 1982 and June 1987 in National Taiwan University Hospital were reviewed and analyzed. They were stratified into two groups, i.e. standard-risk (SR) and high-risk (HR), according to their pre-treatment leukocyte count and age. Following induction therapy, 97% of the SR patients and 80% of the HR patients attained complete remission. In the SR group, the 2- and 3-year failure-free survival rates were 37% and 24%, with a median survival of 16 months. In the HR group, failure-free survival at the second and third year were 11% and 4%, respectively, with a median survival of 5.3 months. Three factors are strongly related to induction failure, i.e. high leukocyte counts (greater than 50*10(9)/1), massive hepatomegaly and large lymph nodes. Univariate analysis of failure-free survival showed six variables with significant detrimental effects on eventual outcomes, i.e. high leukocyte counts (greater than 50*10(9)/1), meningeal leukemia, marked lymphadenopathy, age younger than 2 years and older than 10 years, massive hepatomegaly (greater than 6 cm), and high LDH level (greater than 800 u/1). However, statistical survival models should also determine the joint effects of the prognostic factors so that the relative importance of each factor can be assessed. High initial leukocyte count, disclosed by multivariate analysis, was the single most important factor detrimental to the continuance of complete remission (P = 0.0004). Preliminary results also revealed poor compliance and early relapse in this study. Possible causes of early failure are discussed. Conceptual education for family members, as well as management with effective cytoreductive therapies are urgently needed.

Dyskeratosis congenita preceded by severe aplastic anemia: report of one case

Dyskeratosis congenita is a rare hereditary disease which usually manifests with skin hyperpigmentation, nail dystrophy, and leukoplakia of the mucous membrane (triad). This report describes a six-year-old boy with severe aplastic anemia who was later diagnosed to have dyskeratosis congenita. His unusual presentation was pancytopenia followed by leukoplakia of the tongue, hyperpigmentation of the skin and dystrophy of the nails. Treatment with horse anti-human lymphocyte immunoglobulin (ALG) for his aplastic anemia was not effective.

Extrahepatic biliary obstruction caused by cancer of non-liver origin in children: report of 5 cases

Obstructive jaundice secondary to external compression of the extrahepatic bile duct caused by tumor of non-liver origin was found in 5 of 199 consecutive children with cancer between 1986 and 1988 at the Department of Pediatrics, National Taiwan University Hospital. Of the 5 patients, 2 had non-Hodgkin's lymphoma and the other 3 had acute promyelocytic leukemia, histiocytosis X and neuroblastoma, respectively. Extrahepatic biliary obstruction occurred as part of the initial presentation of malignancy in 3 cases, and later in the course of disease in the other 2 cases. In each instance, abdominal ultrasonography and computed tomography revealed dilatation of intrahepatic biliary trees due to mass compressing effects. A huge multilobulated tumor and multiple enlarged lymph nodes near the porta hepatis were found in all 3 patients who underwent an exploratory laparotomy. Wedge biopsy of the liver showed no cancer cell invasion. One case died before chemotherapy had commenced. The other 4 patients received chemotherapy and 3 of them received additional radiotherapy. Although jaundice and tumor regressed dramatically with this mode of treatments, subsequent recurrence of tumor without jaundice rapidly ensued in 3 patients. They all died, except 1 case, within 18 months from the occurrence of jaundice. This suggests that these patients were in an advanced stage of disease and should be diagnosed early and treated vigorously. Accordingly, cancer of non-liver origin, although rare, should be considered in the differential diagnosis of obstructive jaundice if survival is to be improved in these cancer children.

Bone marrow transplantation for severe aplastic anemia in children: conditioning with cyclophosphamide and total lymphoid irradiation

We used preparative regimens consisting of cyclophosphamide and total lymphoid irradiation in 4 children with severe aplastic anemia undergoing allogeneic bone marrow transplantation. All 4 children engrafted successfully in spite of the number of donors exposed in the previous blood components transfusion. Three of 4 transplanted children have survived for 390 days, 540 days, and 1,235 days respectively. One child died of graft-versus-host disease related sepsis. The actual survival rate was 75% at one year. Further efforts must be aimed at the elimination of graft-versus-host disease and the control of fatal infections.

Reduction in baroreceptor reflex response by angiotension III and its modification by Ile7-angiotensin III and bestatin in the rat

We evaluated the participation of endogenous brain angiotensin III (AIII) in central cardiovascular regulation, using the intracerebroventricular injection technique in Sprague-Dawley rats anesthetized with pentobarbital sodium (50 mg/kg, i.p.). AIII (100 pmol) promoted an elevation in systemic arterial pressure and a reduction in the baroreceptor reflex (BRR) response. Its specific antagonist, Ile7-AIII (100 nmol), and the aminopeptidase inhibitor, bestatin (200 nmol), on the other hand, augmented the response of the same reflex. The suppressive action of AIII (100 pmol) on the BRR was attenuated, and the enhancing effect of Ile7-AIII (100 nmol) was potentiated, however, when these two peptides were administered simultaneously with bestatin (200 nmol). All these events were significantly different from their controls during the first 10-15 min following injection, parallel to the time course of a discernible action of AIII on systemic arterial pressure. We discussed that the endogenous AIII in the central nervous system may participate in cardiovascular control by tonically inhibiting the BRR, in concert with other brain neuropeptides.

Marrow transplantation for thalassemia

Ten patients with homozygous beta thalassemia, aged from 1 year 7 months to 13 years, underwent bone marrow transplantation from siblings or parents. The first case received 12 mg/kg busulfan, 120 mg/kg cyclophosphamide, and 300 cGy total body irradiation before transplantation; he survives, with a graft, more than 680 days after transplantation. The other nine patients received 16 mg/kg busulfan and 200 mg/kg cyclophosphamide. Two died of transplantation-related complications on days 30 and 55. Seven survive 170 to 580 days after transplantation. Three of the seven surviving patients have durable engraftment (greater than 230 to greater than 550 days) while four patients have autologous hematopoietic recovery. Four of five patients who had less than 50 prior transfusions achieved engraftment. Only one of five patients who had more than 50 prior transfusions achieved engraftment (P less than 0.05). The six-month actuarial survival was 80%; six-month actuarial disease-free survival was 40%. These data demonstrate that bone marrow transplantation may cure thalassemia, but engraftment may be jeopardized among patients who have been heavily transfused or have received marrow from a donor who is not HLA-identical.

Effects of bombesin on thermoregulatory responses and hypothalamic neuronal activities in the rat

Direct administration of bombesin (1, 10, and 100 ng/microliter) into the preoptic anterior hypothalamic area caused a dose-related fall in rectal temperature at ambient temperatures (Ta) of 8 and 22 degrees C. The hypothermia in response to bombesin was brought about by a decrease in metabolism at Ta 8 degrees C, whereas at Ta 22 degrees C the hypothermia was brought about by both a decrease in metabolism and an increase in cutaneous temperature. However, at Ta 30 degrees C, intrahypothalamic administration of bombesin caused an insignificant change in thermoregulatory responses. On the other hand, 51 single neurons in the preoptic anterior hypothalamic area were examined in 20 rats under urethan anesthesia. Each animal was subjected to scrotal warming or cooling and to the administration of bombesin. Microiontophoretic application of bombesin resulted in inhibition of the majority (62.5%) of cold-responsive neurons as well as excitation of the majority (50%) of warm-responsive neurons recorded in the preoptic anterior hypothalamic area. However, the majority (74%) of thermally unresponsive neurons were not affected by bombesin application. The data indicate that bombesin, when administered intrahypothalamically, excites warm-responsive neurons and inhibits cold-responsive neurons within the preoptic anterior hypothalamic area to induce hypothermia by promoting an increase in heat loss and a decrease in heat production.

Leucocyte glucose-6-phosphate dehydrogenase (G-6-PD) activity in G-6-PD deficient Chinese

The activity of glucose-6-phosphate dehydrogenase (G-6-PD) in leucocytes was studied for erythrocyte G-6-PD deficiency using 49 hemizygous males, 16 heterozygous females, and 19 normal controls. The mean G-6-PD activity in leucocytes of the affected neonates (9.2 +/- 5.4 units) and the children (11.2 +/- 5.3 units) were significantly lower than those of normal newborns (22.9 +/- 5.1 units, P less than 0.01). Seventy percent of the effected newborns and 58% of the children with G-6-PD deficiency had the leucocyte enzyme activity of less than 13 IU/10(9)WBC. The leucocyte enzyme activity (14.6 +/- 8.6 units) of 16 heterozygous G-6-PD deficient mothers was also lower than that of normal controls (23.1 +/- 7.0 units). The present study thus concludes that, in G-6-PD deficient Chinese, the enzyme defect is demonstrable not only in erythrocytes but also in leucocytes.

Fraternal hepatocellular carcinoma in young children in two families

Two pairs of young brothers from two families with histologically verified hepatocellular carcinoma (HCC) occurred with almost simultaneous onset in each family. In the first family, the boys were 5 and 7 years of age, respectively. Both of them, their parents, and a younger sister were hepatitis-B-surface-antigen (HBsAg)-positive. In the second family, the two brothers were 9 and 7 years of age, respectively. Both patients, their mother, and maternal grandmother were HBsAg-positive. The fraternal occurrence of HCC in children under the age of 10 years has not been reported in the literature. The pattern of HBsAg on these families suggests the HCC cases were infected by their mothers, most possibly in the perinatal period, and is additional support for the important role of hepatitis-B virus in the etiology of HCC. The very early and almost simultaneous onset, however, suggests that additional genetic and/or environmental factors are also important.

[Prevalence of hepatitis virus infections in restaurant workers in Taipei (author's transl)]

Hepatitis B surface antigen (HBsAg) and anti-hepatitis A virus antibody (antiHAV) in sera or saliva of restaurant workers in Chung Shan District, Taipei, were tested by radioimmunoassay from October 1978 to March 1979. Among the 2006 serum samples 387 (19.3%) were HBsAg positive. While significant difference between male and female restaurant workers was observed, no age difference was noted. The workers originated from Taiwan demonstrated the highest frequency of hepatitis B antigenemia (20.9%). The next high group was the workers originated from southern mainland (16.5%). The lowest frequency was observed in those from northern mainland (9.4%). HBsAg was found in saliva of 40 out of 82 serum carriers (48.8%) Of the 946 workers 896 (94.7%) carried the anti-HAV antibody. There was no sex difference and the positive rates were 91.2%, 92.6%, 96.1%, 98.4% in 14--19, 20--24, 25--29 and > 30 years old population, respectively, i.e. a trend of increase in the rates with age was observed.

Disinfection of anesthesia and respiratory therapy equipment with acid glutaraldehyde solution

The dilution of acid glutaraldehyde solution and its effect on microbiological effectiveness were investigated using Sonacide and the Cidematic Decontamination System under normal use conditons at 18 hospitals over a 4-week period. The dilution of Sonacide was found to follow first-order kinetics and is described by the equation, ln C = ln Co-KT, where K is the apparent dilution-rate constant. The average dilution-rate constant under normal use conditions was 0.015/day. It takes an average of 47 days under normal hospital-use conditions to reduce its potency to half its original strength. The average glutaraldehyde concentration after 28 days' use was found to be approximately 66% of the initial concentration. The AOAC use-dilution test was employed to evaluate the microbiological effectiveness of the Sonacide samples collected weekly for four weeks. Results showed that all the Sonacide samples from 18 hospitals passed the AOAC use-dilution test for Pseudomonas aeruginosa (ATCC 15442). Based on this study, it is apparent that Sonacide can be used to disinfect various anesthesia and respiratory therapy equipment for up to 4 weeks in the Cidematic machine.