Pyogenic liver abscess in beta-thalassemia major--report of two cases

Pyogenic liver abscess, which may lead to devastating consequences, is an uncommon medical problem in pediatrics and has generally been reported in compromised hosts. This article describes two patients with beta-thalassemia major and hemochromatosis complicated by Klebsiella pneumoniae liver abscess. One of the patients had severe complications, including subphrenic abscess, pleural effusion and meningitis. To present knowledge, the occurrence of K. pneumoniae liver abscess in patients with beta-thalassemia major has never before been reported in the literature.

Long term clinical and virologic outcome of primary hepatitis C virus infection in children: a prospective study

To investigate the long term natural course of primary hepatitis C virus infection in children from the beginning, we prospectively followed up 88 children at risk because of frequent blood transfusions or of hepatitis C virus infection from the mother. Ten of the 88 children contracted primary infection during follow-up. In the acute stage of infection acute hepatitis with elevation of aminotransferases and a positive IgM antibody was found in both children infected during open heart surgery, 3 of the 5 multiply transfused children with congenital hemolytic anemia and none of the 3 infants infected by their mothers. Four of the 10 children later lost hepatitis C virus RNA, whereas 6 had a chronic course. Three of the latter 6 children had abnormal aminotransferase activities in the chronic phase. Our study suggests that the very young age of primary infection and the underlying status of the host may affect the clinical course of hepatitis C virus infection in children.

Response to supplementary vaccination with recombinant or plasma hepatitis B vaccine in healthy non-responding children

Fifty-three children who failed to respond to four doses of plasma hepatitis B (HB) vaccine (anti-HBs titre < 10 IU l-1) were divided into two groups and received revaccination with either three doses of recombinant HB vaccine (10 micrograms/dose, by 0, 1, 6 month schedule; group A) or two additional doses of plasma HB vaccine (5 micrograms/dose, by 0, 1 month schedule; group B) respectively. Thirty-two vaccinees in group A had a response rate (with anti-HBs > 10 IU l-1) of 53.1% (17/32), 87.5% (28/32), and 100% (32/32) after first, second and third doses of the vaccine respectively. Twenty-one vaccinees in group B had a response rate of 61.9% (13/21) after two additional doses of plasma vaccine. High anti-HBs titres (> 1000 IU l-1) were noted in 50% of the vaccinees in group A after three doses of vaccine. Comparing anti-HBs response between group A and group B after two additional doses of HB vaccine, group A had a higher anti-HBs titre (geometric mean titre 104.7 IU l-1 versus 75.9 IU l-1) along with a better seroconversion rate (87.5 versus 61.9%). However, the differences in vaccine dose between the two groups may also be a contributory factor. Our findings indicate that three doses of recombinant HB vaccine were invariably effective in eliciting a good immune response in previous non-responders to the four doses of plasma HB vaccine. Therefore, it is speculated that these young vaccinees who did not respond to four doses of plasma HB vaccine may not be real non-responders, but hyporesponders.

Posttransfusion hepatitis C virus infection in children

Hepatitis C virus (HCV) infection was investigated retrospectively and prospectively in children who had open heart surgery. The retrospective study included 196 patients who had open heart surgery 2 to 6 years before enrollment and were regularly followed. Antibody to HCV was detected in eight cases, and seven of these eight patients had viremia caused by HCV infection. The other patient's anti-HCV titer gradually decreased and HCV ribonucleic acid was absent throughout the course. Four of these eight had persistent viral replication without clinical evidence of hepatitis; the other three had viremia and chronic hepatitis. The HCV infection rate in the retrospective study group was about 4%. The HCV was of genotype 2 in five cases and of genotype 3 in two cases. The clinical outcome was not related to sex, age, amount of transfusion, or HCV genotype. For the prospective study, we enrolled 94 patients. Of the 56 enrolled after the initiation of anti-HCV screening in the blood bank, none was infected by HCV. Of the 94 patients, 38 were enrolled before screening; 4 had abnormal liver function 1 to 3 months after operation, and 2 were infected with HCV. One patient had an acute but resolving course; the other had persistent anti-HCV and HCV viremia, although the liver function test results returned to the normal range. The HCV in both cases belonged to genotype 2. We conclude that in Taiwan the seroconversion rate of HCV in children who underwent open heart surgery was 4% to 5%. Anti-HCV screening in donor blood significantly decreased the incidence of posttransfusion hepatitis C.

L-asparaginase-related pancreatic pseudocyst: report of a case

Pancreatitis following the administration of L-asparaginase (L-asp) has been well documented. However, the progression of such pancreatitis to pseudocyst formation in some patients has been rarely reported. The few reported cases have been teenagers, with the exception of one adult. All pseudocysts required surgical management. This report documents a pancreatic pseudocyst in a seven-year-old girl with acute lymphoblastic leukemia whose treatment regimen included L-asp. The pseudocyst was managed medically with nasogastric decompression, intravenous hyperalimentation, and antibiotics. The pseudocyst resolved spontaneously in one month without complication.

Temporal profile of hepatitis C virus antibody and genome in infants born to mothers infected with hepatitis C virus but without human immunodeficiency virus coinfection

To investigate mother-to-infant transmission of hepatitis C virus, serial follow-up of anti-HCV and hepatitis C virus RNA was undertaken in 11 infants born to hepatitis C virus-infected mothers who had been screened from 11,688 pregnant women. None of the hepatitis C virus-infected mothers was infected by human immunodeficiency virus. Anti-HCV was checked by the second-generation enzyme immunoassay kit, and hepatitis C virus RNA was examined by reverse transcriptase-nested polymerase chain reaction. Hepatitis C virus RNA was found in more than two serum samples in two of these 11 infants; those two infants were regarded as hepatitis C virus-infected. One of the two had hepatitis C virus RNA at the age of 1, 3, and 6 months, but not later. The course of hepatitis C virus RNA and anti-HCV in this baby may reflect fluctuating viral replication in chronic infectious disease or viral clearance in acute infection. The other infant had hepatitis C virus RNA detectable at the age of 3 months and at 15, 18 and 24 months. In the other nine non-hepatitis C virus-infected infants, maternally acquired anti-HCV gradually disappeared by the age of 6 months. The liver function profile fell to the normal range in all the infants, including the two hepatitis C virus-infected infants. This may indicate the subclinical nature of hepatitis C virus infection in infancy. Seven fathers and four siblings of these 11 infants were checked for anti-HCV and liver function tests; none had evidence of hepatitis C virus infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Possible role of high-titer maternal viremia in perinatal transmission of hepatitis C virus

To study perinatal transmission of hepatitis C virus (HCV), 15 anti-HCV-positive carrier mothers without human immunodeficiency virus coinfection were recruited. At delivery, maternal blood was taken and anti-HCV titer was determined and HCV RNA measured in each serum sample by reverse transcription polymerase chain reaction (PCR). A competitive PCR was used in selected samples to quantitate HCV concentration. The 15 neonates were followed regularly for 1 year and their sera were also assayed for anti-HCV and for HCV RNA by reverse transcription PCR. All the mothers were positive for HCV RNA. Only one normal spontaneously delivered neonate of a mother with extremely high titer of anti-HCV (1:20,000) and HCV concentration (10(10) copies/mL) had both anti-HCV and HCV RNA in serum for up to 6 months of age. In contrast, none of the remaining 14 neonates born to mothers with low- to high-titer anti-HCV (1:4-1:1000) and moderate amounts of HCV RNA (10(5)-10(6) copies/mL) contracted HCV infection. The results imply that high-titer maternal viremia and normal spontaneous delivery may allow more HCV to infect the neonate intrapartum, therefore establishing perinatal transmission.

Analysis of integrated hepatitis B virus DNA and flanking cellular sequences in a childhood hepatocellular carcinoma

The DNA of tumor tissue K1 obtained at autopsy from a case of hepatocellular carcinoma (HCC) in a 9-year-old boy contained integrated hepatitis B virus (HBV) DNA at a single site in the chromosome (case 2, Chang et al.: Hepatology 13:316-320, 1991). To characterize further the integrated viral DNA sequences, a genomic library of the K1 DNA was constructed in the lambda L47.1 vector. One phage clone, designated KTM-1, containing integrated HBV DNA and cellular flanking sequences was obtained from this library. The restriction map and DNA sequence of this clone showed that the integrated HBV DNA was partially deleted and rearranged. The most conserved viral DNA sequences were surface and X genes and arranged in the opposite orientation. The viral core gene was not present. Using chloramphenicol acetyltransferase (CAT) assay, the C-terminal truncated X open reading frame was demonstrated to retain its trans-activating ability. The result suggested that the functional integrated X gene may play a role in hepatocarcinogenesis. The study also showed that the right cellular flanking sequences were human alphoid repetitive sequences.

Amniocentesis in mothers who are hepatitis B virus carriers does not expose the infant to an increased risk of hepatitis B virus infection

Sixty-seven pairs of mothers with hepatitis B virus (HBV) surface antigen (HBsAg) and their infants were divided into two study groups to determine the effect of amniocentesis on intrauterine HBV infection. In the first study group (35 pairs), the infant's HBsAg status in cord blood was studied and the results were compared with those obtained in the cord blood from 65 infants born to HBsAg-positive women who did not have an amniocentesis. In the second study group (32 pairs), the HBV status of the infants was studied at the age of three months to five years and compared with the HBV status of 3,454 infants in the National HBV Prevention Program. In the first study group, one sample (2.9%) was weakly positive for HBsAg; while in the first control group, two (3.1%) were positive. In the second study group, three (10%) infants were positive for HBsAg. The failure rates of immunoprophylaxis in the second study and control groups were similar (9.4% vs 11% for HBsAg carrier mothers; 30% vs 14% for HBe antigen-positive carrier mothers). This suggested that genetic amniocentesis did not increase the risk of intrauterine HBV infection.

Differential diagnosis of extrahepatic biliary atresia from neonatal hepatitis: a prospective study

The clinical presentations of cholestasis in infancy caused by neonatal hepatitis and biliary atresia are very similar. Diagnosis may be difficult on many occasions, but the surgical treatment of biliary atresia should be performed as early as possible. We established a 3-day workup protocol for the differential diagnosis of biliary atresia and neonatal hepatitis and compared the diagnostic accuracy, sensitivity, specificity, and predictive values of various methods. One hundred and twenty-six infants, including 84 with neonatal hepatitis (age, 65.1 +/- 24.1 days) and 42 with biliary atresia (age, 60.3 +/- 31.1 days), were studied prospectively from July 1982 to December 1990. The diagnostic accuracy of various methods was as follows: liver histology, 96.8%; color of duodenal juice, 91.6%; peak radioisotope count in duodenal juice, 84.2%; ultrasonographic examination of the hepatobiliary system, 80.2%; and persistence of clay-colored stool, 80.2%. After stepwise logistic regression, the diagnostic methods of significance were liver biopsy, color of duodenal juice, abdominal ultrasonography, and stool color. However, stool color and the onset of jaundice could not differentiate severe neonatal hepatitis from biliary atresia. The diagnostic methods of significance then were liver biopsy and duodenal juice color. With this 3-day protocol, no biliary atresia was missed although four cases of neonatal hepatitis were misdiagnosed, resulting in unnecessary laparotomy; we found an overall diagnostic accuracy of 96.8%. We conclude that this 3-day diagnostic protocol is very helpful in the differential diagnosis of neonatal hepatitis and biliary atresia. Liver histologic examination is the most reliable single test for the differential diagnosis.

Gastrointestinal bleeding and paraparesis in blue rubber bleb nevus syndrome

Blue rubber bleb nevus syndrome (BRBNS), which consists of cutaneous and visceral hemangiomas, is a rare disease. Complications such as gastrointestinal (GI) bleeding, anemia and coagulopathy have been documented. We report a patient with BRBNS who presented with acute paraparesis in addition to GI bleeding and coagulopathy.

Association of HLA-DR14-DR52 with low responsiveness to hepatitis B vaccine in Chinese residents in Taiwan

To determine the HLA-linked immune response gene that controls low responsiveness to hepatitis B surface antigen (HBsAg), HLA typing was performed in 33 initial non-responders (male:female = 23:10, age 1.5-46 years) who had poor antibody response (anti-HBs < 10 mIU ml-1) after four doses of plasma-derived hepatitis B vaccine. Of 33 initial non-responders, 26 received two additional doses of either the same vaccine (n = 18) or recombinant hepatitis B vaccine (n = 8) and returned for anti-HBs measurement. At 1 month after the sixth dose, anti-HBs was still < 10 mIU ml-1 in 20 cases and 10-20 mIU ml-1 in three cases. Analysis of HLA antigen frequencies in these 23 ultimate low responders revealed that nine (39%) were positive for DR14, a statistically significant association of low responsiveness to hepatitis B vaccine with HLA-DR14. In addition, 26% of the ultimate low-responders were positive for DQ3, a frequency significantly lower than the expected rate in the general population. Among the nine ultimate low-responders with DR14, seven were heterozygous for this allele, while the other two cases had a single isolated DR14; and all nine were in association with DR52. These results suggest that a DR14-DR52 association, probably dominantly expressed, may be involved in the low immune responsiveness to hepatitis B vaccine of the Chinese population in Taiwan.

Gastrointestinal perforation in infants: cases unrelated to necrotizing enterocolitis

From January 1984 to March 1992, there were 19 infants admitted to our hospital with gastrointestinal perforation not associated with necrotizing enterocolitis. Seven patients (37%) were premature. Six patients (32%) had their perforations located in the stomach, 9 (47%) in the small intestine, and 3 (16%) in the colon. The most common clinical presentation was abdominal distention (95%). Pneumoperitoneum was noted only in 12 (63%) patients. About 60% of the patients had the perforation occur before 4 days of age. The predominant cause of perforation was unknown, so called spontaneous perforation (8/19, 42%), followed by ischemia or infarction (5/19, 26%). The overall mortality rate was 32%. The non-survivors had more severe metabolic acidosis than the survivors, but there were no differences in the birthweight and gestational ages of these two groups. Sepsis accounted for 83% of the deaths. Early diagnosis and treatment are the best ways to promote survival.

Fungal esophagitis in children

Seven patients were endoscopically diagnosed as having a fungal esophagitis with mycologic or histologic support for the diagnosis from 1979 to 1991 in the Department of Pediatrics, National Taiwan University Hospital. The major causative agent was Candida albicans. Other fungi isolated were Candida Krusei, Trichosporon cutaneum, Trichosporon beigelii, and Rhodotorula rubra, but they all resembled one another under endoscopic examination. The most common presenting symptom was hematemesis, and the lower part of the esophagus was more often involved. Only one patient was documented to have oral thrush. Most of the children did not present typical symptoms of esophagitis such as dysphagia or odynophagia, and they tended to be in more advanced stages of the disease when the diagnosis was made.

Minimal role of hepatitis C virus infection in childhood liver diseases in an area hyperendemic for hepatitis B infection

To investigate the role of hepatitis C virus (HCV) in childhood liver disease in Taiwan, an area hyperendemic for hepatitis B, we studied antibody to HCV (anti-HCV) with a second generation enzyme immunoassay in 195 infants and children, including 96 hepatitis B surface antigen (HBsAg) positive children (66 with chronic hepatitis B, 23 children with hepatocellular carcinoma, and 7 with fulminant hepatitis B), 6 children with fulminant non-A, non-B hepatitis, 42 infants with neonatal hepatitis, 11 with biliary atresia, and 40 prospectively followed blood recipients. For comparison, another 748 apparently healthy children (from neonates to 12 years) were also screened for anti-HCV. The positive rate of anti-HCV was low in both apparently healthy children (0.13%) and patients with various liver disorders (0 to 4.4%) except fulminant hepatitis. The seropositive rate in 6 cases of non-A, non-B fulminant hepatitis was higher (16.7%) although the case number was too small. We conclude that HCV is generally not a major etiologic factor in the liver diseases of Taiwanese children.

Hepatitis B virus in the colostra of HBeAg-positive carrier mothers

To investigate the amount of hepatitis B virus (HBV) in colostra of hepatitis B e antigen (HBeAg)-positive carrier mothers and the relationship of HBV amount between colostrum and maternal blood, 50 HBeAg-positive carrier mothers were recruited and studied for hepatitis B surface antigen (HBsAg) titer, HBeAg titer, and HBV-DNA concentration in their sera and colostra. According to the presence or absence of seral HBV-DNA determined by dot hybridization, these 50 HBeAg-positive carrier mothers could be divided into two groups: group 1 (n = 28, HBV-DNA < 0.04 ng/ml), and group 2 (n = 22, HBV-DNA > or = 0.04 ng/ml). The colostral HBsAg and HBeAg titers were both significantly higher in group 2 than in group 1. In addition, both colostral HBsAg and HBeAg titers had positive correlation with each corresponding maternal blood. Although the colostral HBV-DNA was undetectable by dot hybridization, all were positive by polymerase chain reaction with Southern blot hybridization. Because HBV-DNA can be detected in all HBeAg-positive carrier mother's milk, it reinforces the necessity of hepatitis B vaccination for the neonates born to these carrier mothers, particularly in countries with a high carrier rate.

Safety and immunogenicity of hepatitis A vaccine in healthy adult volunteers

The immunogenicity and adverse reaction of an inactivated hepatitis A (HA) vaccine were investigated. Sixty healthy adult volunteers who lacked antibody to HA virus (anti-HAV) received three doses of vaccine containing 720 enzyme-linked immunosorbent assay (ELISA) units (EL.U) according to a 0, 1 and 6 month schedule. Blood tests for serum liver enzymes and anti-HAV were performed at screening 7 days prior to, and 1, 6 and 7 months after the first dose. Anti-HAV was tested by radio immunoassay and ELISA for titre determination. The seroconversion rates measured by ELISA were 98.3% (59/60) at months 1 and 6 and 100% at month 7. Sixty-one per cent (109/180) of the documented injections were followed by local symptoms, essentially mild soreness at the site of injection; and 22.2% (40/180) by minor general symptoms including malaise, fatigue and lethargy. It is concluded that HA vaccine is highly immunogenic and safe. It may replace immunoglobulin as an effective method of preventing HA virus infection in adults.

Total parenteral nutrition-associated cholestasis in infants: clinical and liver histologic studies

To evaluate total parenteral nutrition-associated cholestasis (TPN-C) in infants, a retrospective clinicopathologic study was conducted of 15 infants who had received TPN. The mean gestational age and birth weight were 32.1 weeks (26-40 weeks) and 1807 g (840-5840 g) respectively. Two-thirds of the patients were kept on TPN for more than 60 days. The onset of rising direct bilirubin ranged 2-9 weeks (mean 4.5 +/- 2.4) after TPN therapy. Preterm babies less than 32 weeks of age had an earlier rise of direct bilirubin and AST. Bile sludge of the gallbladder was observed in only one case, and none had gallstone. The main histologic findings of liver biopsy or autopsy were cholestasis (intracellular and canalicular), periportal inflammation, fibrosis and bile ductular proliferation. Sixty percent of these survived, the remaining 40% died of complications unrelated to TPN-C. The liver function profile became normalized within a mean of 14.0 +/- 9.4 (8-34) weeks after discontinuation of TPN in the survival cases. It was concluded that infant TPN-associated cholestasis was mostly reversible, but that the younger preterm babies were susceptible to a prolonged TPN course with more marked clinical and pathological changes.

Growth and body composition of preterm, small-for-gestational-age infants at a postmenstrual age of 37-40 weeks

In order to understand the nutritional status of preterm, small-for-gestational-age (SGA) infants in the early postnatal period, the growth and body composition of preterm, SGA infants was followed prospectively from birth to the postmenstrual age of 37-40 weeks. The infants were stratified into different groups by gestational age, clinical condition and body proportionality. In each subgroup, the growth and changes in body composition of SGA infants were compared with appropriate-for-gestational-age (AGA) infants of a comparable postmenstrual age. At birth, the SGA infants of both the 31-33 and 34-36 week gestational-age groups were smaller than AGA infants in all body measurements, including arm area (AA), arm muscle area (AMA) and arm fat area (AFA). When the preterm SGA infants had grown to the postmenstrual age of 37-40 weeks, the amount of fat they had accumulated was as much as, or more than that in term AGA infants. Yet, they had less muscle mass and their body weight, body length and head circumference were less than those in term AGA infants. This pattern of growth and the changes in body composition had been persistently observed in SGA infants of different gestational-age groups, different clinical status and different body proportionality. Differences between postnatal enteral nutrition and placental nutrition, or different energy utilization, in preterm SGA infants are hypothesized to account for these observations. The growth of less mature (31-33 weeks gestation) SGA infants and those preterm SGA infants with an eventful clinical course was suboptimal as compared with other SGA infants in the same subgroup. In this study, the weight to length ratio (WLR) was used to define the status of nutrition in preterm SGA infants: WLR < or = 2 S.D. or > 2 S.D. off the reference mean. Infants in both groups showed some catch-up growth in body weight. Yet, at near-term their body weight were still more than 2 S.D. below the mean of term AGA. In each gestational-age group, the growth of these two body-proportionality groups did not differ from each other except for the low WLR group of 34-36 weeks gestation which had a significantly lower body weight and skinfold thickness than the group with a normal WLR. Multiple regression analysis revealed that skinfold measurements of preterm SGA infants at birth is the best factor for determining the body weight gain at near-term. After use of the skinfold thickness was set aside, WLR became the most important factor.(ABSTRACT TRUNCATED AT 400 WORDS)

Safety and immunogenicity of hepatitis A vaccine in healthy children

The immunogenicity and reactogenicity of an inactivated hepatitis A (HA) vaccine in children were investigated. One hundred three healthy children who lacked antibody to HA virus (anti-HA virus), aged between 3 months and 6 years 8 months, were enrolled in this study. They received three doses of 360 enzyme-linked immunosorbent assay units of HA vaccine in a 0-, 1- and 6-month schedule. Blood tests for aminotransferase and anti-HA virus were performed 7 days before and 1, 6 and 7 months after the first dose. Anti-HA virus was tested by radioimmunoassay and also by enzyme immunoassay for titer determination. The seroconversion rates measured by enzyme immunoassay were 95.1% (98 of 103) at Month 1 and 100% at Months 6 and 7. Nine percent (28 of 309) of the injections were followed by local symptoms, usually mild soreness and swelling at the site of injection, and 12% (37 of 309) by minor general symptoms. We conclude that HA vaccine is highly immunogenic and safe in children. It may replace immunoglobulin as an effective method to prevent HA virus infection in children. We also suggest that the HA vaccine be administered to children in endemic areas.

Weight to length ratio--a good parameter for determining nutritional status in preterm and full-term newborns

To identify which parameter showed the strongest correlation with neonatal body fat store, when the ratios for assessing both weight-for-length and the mid-arm circumference to head circumference (MAC/HC) were included in the analysis, body anthropometrics and skinfold thickness were measured in 250 full-term and 125 preterm infants. Among the study cases, 66.7% were appropriate for gestational age, 26.7% were small for gestational age and 6.7% were large for gestational age. Sum of the skinfold thickness measured at the midtricepital and subscapular areas correlated well with body anthropometrics, weight/length ratio, body mass index, ponderal index and mid-arm circumference to head circumference ratio. Multiple stepwise regression analysis revealed that the weight/length ratio correlated best with skinfold thickness in both full-term and preterm newborn infants. Therefore, the simple weight/length ratio might be useful for evaluation of the nutritional status of intrauterine growth, and in the prediction of metabolic complications in both full-term and preterm newborns with abnormal intrauterine growth.

Proximal slowing in carpal tunnel syndrome resulting from either conduction block or retrograde degeneration

In the carpal tunnel syndrome (CTS), decreased conduction velocity (CV) of the median nerve in the forearm segment has been ascribed to an electrodiagnostic artefact rather than pathophysiological changes. Standard CV of the forearm segment is calculated by subtracting the distal latency, which may not represent an exact assessment of CV in the proximal median nerve. A new technique modified from the method of Stoehr et al. and Pease et al. can exactly measure CV over the forearm. Using this new technique, the forearm nerve action potentials (FNAP) amplitude and forearm nerve conduction velocity (FNCV) proximal to the wrist can be directly determined. Normal subjects and patients with CTS were studied by both the standard and the new FNAP methods. Patients were divided into subgroups according to the severity derived from standard electro-diagnostic findings. By comparing the normal control and patient subgroups, the results show that there was a significant decrease in FNAP amplitudes proportional to severity, but FNCV was reduced to a lesser extent. In addition, the standard forearm median motor CV (MMCV) correlated well with severity, but the reduced MMCV did not correlate with the decreased FNCV. These findings suggest that retrograde degeneration of the median nerve does exist in CTS; however, retrograde degeneration contributes little to the reduced forearm MMCV which substantially results from the block of faster conduction fibres at the wrist. Therefore, technique artefact plays a major role in causing the proximal slowing in the standard electrodiagnosis.

Association of hiatus hernia with asplenia syndrome

During a 13-month period, 13 patients with asplenia syndrome were evaluated with MRI for cardiovascular and visceral anomalies. The MR images were reviewed for the presence of haitus hernia which was found in three patients. One of the remaining ten patients with no MRI evidence of hiatus hernia was diagnosed as having gastro-oesophageal reflux and hiatus hernia by an oesophagogram and 24-h pH monitoring. This patient had undergone fundoplication prior to MRI. Out of the 13 patients (31%) with asplenia syndrome, 4 had hiatus hernia. It appears that among patients with the asplenia syndrome, hiatus hernia is a frequent finding. Recurrent pneumonia or bronchiolitis in patients with asplenia syndrome requires evaluation for the presence of hiatus hernia and gastro-oesophageal reflux.

Primary infections of Epstein-Barr virus, cytomegalovirus, and human herpesvirus-6

A total of 121 infants entered a cohort serological study of primary infections with herpes-viruses. All of them had seven samples of blood available: the first sample was taken soon after birth, the other six were taken at 1, 2, 3, 6, 12, and 14 months of age. One sample of maternal blood was collected immediately after delivery. All blood samples were tested for antibodies against cytomegalovirus, Epstein-Barr virus, and human herpesvirus-6 (HHV-6). Primary cytomegalovirus infection occurred early; the cumulative infection rates were 1.7%, 8.3%, 18.3%, 25%, 52.5%, and 65% by the ages of 1, 2, 3, 6, 12, and 14 months, respectively. Epstein-Barr virus infection was not seen before 3 months of age and slowly emerged thereafter, reaching a cumulative rate of 1.7%, 11.6%, 21.5% at the ages of 6, 12, and 14 months, respectively. Primary HHV-6 infection was also a rare event in the first three months of life, but peaked between 6 and 12 months of age. No detectable risk factors were associated with primary Epstein-Barr virus or HHV-6 infection. The risk factors associated with cytomegalovirus infection included breast feeding, fewer children in household, and care by a babysitter.

Indices of body proportionality in neonates

The inadequacy of using body weight alone to evaluate fetal skeletal and soft-tissue growth has long been recognized. Body proportionality indices could identify symptomatic newborn infants better than size-for-date classification. Lack of normative data precludes its being used, practically, in Chinese newborns. Thus body weight, body length, head circumference and mid-arm circumference were measured in 240 neonates appropriate for gestational age, 27-42 weeks, 960-3918 g, to construct reference indices of body proportionality: ponderal index (PI), body mass index (BMI), weight/length ratio (W/L), head circumference/body length ratio (HC/L) and mid-arm circumference/head circumference ratio (MAC/HC). All the five indices of body proportionality but HC/L were statistically correlated with gestational age (GA). For full-term newborns, PI did not correlate with GA. Furthers, the MAC/HC ratio decreased after 40 weeks' gestation. Therefore, when these indices of body proportionality are used to evaluate intrauterine nutritional status of a newborn, the appropriate standard for GA should be considered.

Absence or delayed appearance of hepatitis B core antibody in chronic hepatitis B surface antigen carrier children

An absence of the hepatitis B core antibody (anti-HBc) in hepatitis B surface antigen (HBsAg) carrier children has been reported before, but whether anti-HBc will ultimately appear is unknown. In a group of 420 HBsAg carrier children who were followed longitudinally, 10 (2.4%) had an absence or delayed appearance of serum anti-HBc. These 10 children were persistently seropositive for HBsAg, hepatitis B e-antigen, and hepatitis B virus DNA (HBV-DNA). Anti-HBc never appeared in 4, one of whom was a case of hepatitis B vaccine failure and became an HBsAg carrier. Three of the 4 were born to HBsAg carrier mothers. Liver biopsy in one revealed non-specific reactive hepatitis (NSRH). All 4 were asymptomatic during follow-up. Mothers of the other 6 children who had delayed appearance of anti-HBc were also HBsAg carriers. The children seroconverted to anti-HBc positivity between 2 and 8 years of age, and the titer of serum anti-HBc at the first appearance varied. There were no significant changes in liver function tests, HBV-DNA levels, or associated symptoms and signs before and after seroconversion. Liver biopsies were performed before anti-HBc seroconversion in 2 children and showed NSRH. All 10 children had a moderate to high replication of HBV as shown by the high titer of HBsAg and HBV-DNA. The absence of anti-HBc occurred almost exclusively in children who were infected perinatally.(ABSTRACT TRUNCATED AT 250 WORDS)

Patterns of hepatitis B virus DNA integration in liver tissue of children with chronic infections

Although an integration of hepatitis B virus (HBV) DNA in children with chronic HBV infection has been documented at early phases of the disease, the incidence of this process is not known. Therefore we examined nine liver DNA specimens from chronic HBV carriers ages 5-14 years and one sample from a neonate delivered of a carrier mother, in order to determine the HBV DNA patterns of these patients at different ages and phases of chronic infection. The integrated HBV DNA was detected by Southern blot hybridization and analyzed by molecular cloning. Southern blot showed a smear pattern of HBV DNA integration in four of six chronic hepatitis patients (ages 5-14), as well as in one asymptomatic carrier (age 12). Multiple and random integrations occurred during chronic infections in childhood. The neonate did not, however, show signs of any integrations, suggesting that integration starts after HBV multiplication. A band pattern that suggested clonal growth of integrated liver cells was found in a chronic active hepatitis patient (age 9) and in one of two hepatocellular carcinoma patients (age 11). Molecular cloning in two cases with chronic active hepatitis showed that the HBV genome structure was preserved in five of six HBV DNA inserts. Our findings confirm that HBV DNA integration can occur at early stages of chronic HBV infection. In Japanese children, the process of integration seems to be common regardless of HBeAg/anti-HBe status.(ABSTRACT TRUNCATED AT 250 WORDS)

"Numb, clumsy hands" and tactile agnosia secondary to high cervical spondylotic myelopathy: a clinical and electrophysiological correlation

Four patients presented with a distinctive syndrome of "numb, clumsy hand" and tactile agnosia. Myelography and computed tomographic myelography (CTM) of the cervical spine documented major spondylotic compressive lesions mainly between the C3 and C5 levels. The cortical responses of dermatomal somatosensory evoked potentials (DSEPs) revealed progressively prolonged peak latencies and progressively decreased amplitudes of early components from C6 to C8 dermatomal stimulation. In comparison, the C5 and L2 DSEPs were affected to a lesser extent. This finding suggests that high cervical cord compression may produce dysfunction of the dorsal column caudal to the direct compressive sites. In other words, the funiculus cuneatus of C6-8 cord is most affected in high cervical myelopathy. Moreover, the funiculus cuneatus is within the border zone susceptible to an overall reduction in blood flow. We conclude therefore, that ischemia secondary to cord compression is the pathophysiology resulting in this unique syndrome of "numb, clumsy hands" and tactile agnosia.

Rotor's syndrome: report of one case

Rotor's syndrome is a rare hereditary non-hemolytic hyperbilirubinemia. This report concerns an 11-year-old boy who presented with fluctuant jaundice since birth. Liver function tests showed conjugated hyperbilirubinemia with normal serum aminotransferase and globulin level. The diagnosis was confirmed by laboratory workup which included normal liver histology and oral cholecystography and typical sulfobromophthalein excretion curve.

Polymerase chain reaction to detect human cytomegalovirus in livers of infants with neonatal hepatitis

Neonatal hepatitis is closely related to human cytomegalovirus infection in Taiwan, a conclusion based on serological and urine culture studies. To obtain more direct evidence further relating cytomegalovirus to the pathogenesis of neonatal hepatitis, the cytomegalovirus genome was studied in the liver tissues of 50 infants with neonatal hepatitis using the polymerase chain reaction (PCR). Liver tissues from 26 infants with biliary atresia and another 30 infants and children with diagnoses other than neonatal hepatitis, cholestasis, or hepatitis were also studied for comparison. Sequences from the immediate early gene 1 and 2 regions were used as primers. The liver tissues from 23 (46%) of the 50 infants with neonatal hepatitis were positive for cytomegalovirus genome, whereas those of 2 of the 26 infants with biliary atresia and none of the liver tissues from 30 infants and children without neonatal hepatitis were positive for cytomegalovirus genome, by PCR. The results of PCR correlated well with that of serology and urine culture. This study provides further evidence of cytomegalovirus in the pathogenesis of neonatal hepatitis.

Distal paresthesia in patients with cervical cord lesions

Nine patients complaining of distal paresthesia were found to have spinal cord lesions with no evidence of peripheral nerve disease. This pattern may be due to central nervous system dysfunction, with a lesion being intramedullary or extramedullary. The sensory deficits were initially asymmetric. Paresthesias could originate from the hands and progress to the stocking-glove pattern. It was usually more severe in hands than in feet. The abnormal somatosensory evoked potentials, found in all patients, indicated a lesion involving the posterior column, a site supposed to be the pathologic basis of paresthesia. As hands and feet have relatively large somatotopic representation in the posterior column of the cervical cord, the paresthesia tends to localize over distal portions of extremities.

Cytomegalovirus-associated neonatal hepatitis

Fifty-five patients with cytomegalovirus (CMV)-associated neonatal hepatitis (NH) were followed for 12 to 90 months. Six patients (10.9%) died from either a fulminant course or a chronic liver disease. Among the remaining 49 patients, whose liver function was completely recovered, there were eight with retardation of developmental or growth status, and two with hearing impairment. Overall, 20.4% of the survivors suffered from a long-term impact. The unfavorable outcome was related to several clinical and pathological parameters. These included persistence of clay-colored stool, presence of splenomegaly, ascites or anemia, high peak total and direct bilirubin, low nadir albumin levels, diffuse giant cell transformation and cirrhosis of the liver. The seropositivity of CMV infection did not significantly correlate with the outcome.

Correlation between ELISA and recombinant immunoblot assay in serum samples positive for anti-HCV

To determine the false-positivity of antibody to hepatitis C virus (HCV) (anti-C100-3), the correlation between ELISA optical density (OD), anti-HCV titer and recombinant immunoblot assay (RIBA) in 87 anti-HCV-positive sera was analyzed. The results showed that > 90% of the serum samples with an anti-HCV OD > 2.0 or with titers > 10 x were RIBA reactive. These findings are applicable in daily clinical practice.

Cellular immune response to HBcAg in mother-to-infant transmission of hepatitis B virus

Cellular immunity to HBcAg was studied in hepatitis B virus carrier children and neonates born to hepatitis B virus carrier mothers. A significant proliferative response of peripheral blood mononuclear cells to HBcAg was found in 5 of 10 children with elevated ALT levels but in none of the nine HBeAg-positive children with normal ALT levels. HBeAg but not HBsAg was detected in cord blood of 9 of 10 neonates born to HBeAg-positive carrier mothers, suggesting exposure of these neonates to HBeAg in utero. However, cord mononuclear cells from neonates born to HBeAg-positive carrier mothers did not show a significant change in the proportion of suppressor and helper T-cell subsets or proliferative response to HBcAg. Nor did they produce interleukin-2 receptor after being cocultured with HBcAg. The unresponsiveness of peripheral-blood mononuclear cells or cord mononuclear cells to HBcAg was not reversed by CD8+ cell depletion. Although cord blood mononuclear cells from neonates born to carrier mothers positive for antibody to HBeAg also did not respond to HBcAg, we encountered an infant, born to a carrier mother positive for antibody to HBeAg, who contracted acute hepatitis B at 2.5 mo of age. The baby's peripheral-blood mononuclear cells showed a significant proliferative response to HBcAg. These results support the view that transplacental maternal HBeAg probably induces a specific unresponsiveness of helper T cells to HBcAg and HBeAg in the neonates born to HBeAg-positive carrier mothers. This specific helper T cell tolerance could be maintained throughout the early replicative phase of carrier state but might break someday with the appearance of raised ALT level.

Congenital short bowel syndrome: report of a case treated with home central parenteral nutrition

Congenital short bowel is a rare anomaly. Among the 21 cases reviewed in the literature, only four (19%) survived beyond infancy. We present a female infant with short small bowel, malrotation and floating colon, who was successfully treated with home central parenteral nutrition. Improved long-term survival in this group of patients is expected with prolonged parenteral nutritional support.

Serum gastrin levels in children with peptic ulcer disease

Fasting serum gastrin values were measured by radioimmunoassay in 53 children with peptic ulcer disease. The mean fasting serum gastrin levels for children with chronic duodenal ulcer, acute gastric ulcer, acute duodenal ulcer who were younger than two years old and acute duodenal ulcer who were older than two years old were: 46.2 +/- 25.7 pg/mL, 46.9 +/- 43.5 pg/mL, 47.9 +/- 12.0 pg/mL and 37.5 +/- 17.8 pg/mL, respectively. Children with peptic ulcer disease did not have elevated fasting serum gastrin levels when compared with age-matched controls. We conclude that a fasting serum gastrin value cannot be used as a screening test for peptic ulcer disease in children, except for Zollinger-Ellison syndrome.

Spontaneous loss of HBsAg in children with chronic hepatitis B virus infection

Spontaneous loss of HBsAg is infrequent in adult HBV carriers. Little is known about this serological change in children. In a prospective study of 420 hepatitis B virus-carrier children who were observed for 1 to 12 yr (mean = 4.3 yr), spontaneous loss of HBsAg occurred in 10 patients, with an average incidence of 0.6%/yr. The HBsAg clearance rate was significantly higher in children who had anti-HBe; children who were at an older age on entry; children whose mothers were HBsAg-; or children with severe liver histological changes detected while they were HBeAg+. Children who seroconverted from HBeAg to anti-HBe before the age of 6 or who had a peak serum ALT level above 100 IU/L were more likely to clear HBsAg. In all 10 patients who became HBsAg-, serum hepatitis B virus DNA became undetectable by both spot hybridization and the polymerase chain reaction, suggesting a complete clearance of the virus from serum. After the loss of HBsAg, the anti-HBs levels were higher in the children born to carrier mothers than in those born to noncarrier mothers. These findings suggest that chronic hepatitis B virus-carrier children rarely lose HBsAg, especially if they have been infected during the perinatal period and have mild histological changes. The poor humoral immune response to HBsAg may be a contributing factor in the establishment of carrier status during horizontal infection but may not be primarily involved in the establishment of carrier status during perinatal infection.

Changing seroepidemiological patterns of cytomegalovirus infection in children in Taiwan from 1984 to 1989

The prevalence of cytomegalovirus (CMV) antibody was studied in 966 children in 1984 and 927 children in 1989. The overall prevalence rate of CMV antibody was 59% for children in 1984 and 46% for children in 1989 (P less than 0.05). In both study years, the prevalence rate of CMV antibody was about 70% in infants under 6 months of age, declined to a trough between the ages of 6 and 12 months, and then increased to 40-50% between 1 and 4 years of age. The rate of CMV antibody for children above 4 years in 1984 increased steadily with age and reached 82% by 12 years. In contrast, the prevalence rate in 1989 remained at the level of 40-50% from age 4 to 10 years. It was followed by a sharp increase after 10 years of age and reached 84% at 12 years old. The seropositive rate in each of the 5-, 6-, 8-, 9-, and 10-year-old groups was higher in 1984 than that in 1989. These observations indicated that the prevalence rate of CMV antibody is decreasing in children. This change may be related to various socioeconomic factors, especially the less crowded family conditions in recent years.

Prevalence of antibody to Epstein-Barr virus DNase in children

Antibodies to Epstein-Barr-virus-specific DNase in children under 15 years old from Taipei, Taiwan were determined by an enzyme neutralization test. Serum was taken as positive for the anti-DNase antibody when 1 ml of serum could neutralize > or = 2 units of the DNase activity. Among the 1,292 sera tested, 5.6% of the children were shown to have anti-EBV DNase antibodies, a result similar to that for adults. Maternal antibodies against the EBV DNase were found to decrease very rapidly 2 months after the child's birth, and new antibody appeared upon natural EBV infection.

Transfusion-acquired cytomegalovirus infection in children in a hyperendemic area

Thirty-nine children without previous cytomegalovirus (CMV) infection received blood transfusion in the National Taiwan University Hospital. The overall transfusion-acquired CMV infection rate was 36% (14/39). Donor CMV seropositive rate was 70%. None of the nine children who had received seronegative blood became infected, in contrast to 14 of the 21 children (67%) who had received seropositive blood (P = 0.002). Another significant risk factor associated with CMV infection was the use of fresh blood: 13 of 15 (87%) with fresh seropositive blood were infected, in contrast to one of six (17%) with "old" seropositive blood (P = 0.01). Most of the fresh blood was used within 24 hours. This blood processing method was shown to account for the extremely high rate of CMV infection in those who had received fresh seropositive blood. The results indicated that the incidence of CMV infection can be reduced by avoiding the use of fresh blood, especially blood less than 24 hours old. For such a population in Taiwan with high prevalence of positive CMV antibody, this approach was more applicable than screening donor blood for CMV antibody.

Congenital intractable diarrhea with possible defective crypt regeneration: report of a case

A male infant, born uneventfully from a consanguinous marriage, presented with intractable watery diarrhea from his third day of life, with subsequent malnutrition and failure to thrive. He received central parenteral nutrition beginning at three months of age after a poor response to a semielemental diet and peripheral parenteral nutrition. He was totally dependent on central parenteral nutrition thereafter. Although diarrhea disappeared with strict bowel rest, intolerance to minimal enteral feedings persisted throughout his 2 years 4 months of life. Investigations including stool examinations and repeated cultures, immune function studies, radiologic studies of the small bowel and screening for galactosemia and cystic fibrosis could not demonstrate a specific cause for the diarrhea. Repeated small intestinal biopsies at 1 month, 4 months and 1 year 5 months of age showed persistent villous atrophy with crypt hypoplasia and a low crypt mitotic index. Electron microscopic examination revealed normal-appearing microvilli. This child may have had a congenital enteropathy due to an inborn crypt regeneration defect causing lifelong intolerance to enteral feedings.

Low prevalence of hepatitis C virus and infrequent perinatal or spouse infections in pregnant women in Taiwan

To assess the prevalence of hepatitis C virus (HCV) infection in the pregnant women in Taiwan, we investigated two groups of pregnant women, 944 women without serum alanine aminotransferase (ALT) screening (group A) and 197 women with abnormal ALT (greater than 45 IU/L) (group B). They were checked for anti-HCV (anti-C100-3) with HCV EIA kit (Abbott Lab., North Chicago, IL). The results showed that 21 (2.2%) in group A and 5 (2.5%) in group B were anti-HCV-positive. However, 15 out of 21 in group A had an optical density (O.D.) of anti-HCV less than 1.0, were negative by recombinant immunoblot assay (RIBA), and were regarded as false-positive. Nine infants delivered by those 11 cases were negative for anti-HCV at 6 months of age, while none of the 8 husbands were anti-HCV-positive. It is concluded that the prevalence of anti-HCV in pregnant women in Taiwan is low (6/944, 0.63%), even in the cases with abnormal ALT (5/197, 2.5%). There was no serologic evidence for perinatal transmission or spouse infection.

Hepatocellular carcinoma in childhood. Clinical manifestations and prognosis

From December 1964 to November 1989, 71 children from 3 to 17 years of age with the eventual diagnosis of hepatocellular carcinoma (HCC) presented at the National Taiwan University Hospital (Taipei, Taiwan, Republic of China). Forty-three of them had pathologic proof, whereas 28 were diagnosed on a clinical and laboratory basis. A male predominance (M:F = 3.2:1) was noticed. Most patients presented in a late, advanced stage. Abdominal pain and abdominal mass were the major symptoms and signs, followed by anorexia, fever, and internal bleeding. Hydrocele, purpura, and obstructive jaundice were rare presenting symptoms. Hepatosplenomegaly, superficial venous engorgement, and ascites were the main physical signs. The prognosis for such children with HCC was very poor. Only 10% of the patients survived longer than 1 year after the onset of the initial symptom. Among 49 patients who could be followed, only two had long-term survival of over 5 years. One patient had a small HCC with internal bleeding, whereas the other had a large HCC with abdominal distention. Both received surgical resection, and a resection was repeated for tumor recurrence in the patient with the large mass. The resectability of these 71 patients was low (9.8%). Resectability and nonicterus seemed to be the factors indicating favourable prognosis. Observation indicated that the prognosis for children with symptomatic HCC is grave but surgical resection, whenever possible, should be carried out.