Two siblings with Fanconi anemia (FANCQ, ERCC4/XPF) presenting with tumor-mimicking lesions in the brain and acute neurological deterioration

The complementation Q group (FANCQ) subtype of Fanconi anemia (FA) caused by the ERCC4/XPF mutation is very rare. Two siblings, aged 13 and 10 with Fanconi phenotypic features, presented with right hemiparesis and focal-onset seizures. In both cases, cranial magnetic resonance imaging (MRI) showed mass-like lesions accompanied by peripheral edema and calcification. In one case, oral steroid treatment and surgical excision were performed, while in the other case, the cranial lesion regressed just with steroid treatment and without surgery. Both siblings remained wheelchair-bound due to neurological dysfunction. One case died due to hepatocellular carcinoma. ERCC4/XPF gene mutation was detected in both siblings.

Thrombin generation assay in platelet-poor plasma in children with iron deficiency anemia

OBJECTIVES

Iron deficiency anemia (IDA) is the most common type of anemia in childhood and it leads to a hypercoagulable state. We investigated endogenous thrombin production in platelet-poor plasma before and after oral iron replacement in children with IDA using the thrombin generation assay (TGA).

METHODS

A total of 72 children diagnosed with IDA (IDA group) and 60 healthy children (control group) were included in the study. Blood samples were collected from the patients before and 1 month after oral iron replacement. TGA parameters [lag time, time to peak, peak height, endogenous thrombin potential (ETP)] were studied.

RESULTS

In the IDA group, the lag time and time to peak decreased by 8.3% and 10.6%, respectively, and the endogenous thrombin potential (ETP) and peak height both increased by 30% compared to those of the control group. Compared to the values before iron replacement, 1 month after iron replacement, the lag time and time to peak increased by 8.7% and 5%, respectively, and the ETP and peak height decreased by 31% and 31.3%, respectively, and became similar to those of the control group.

CONCLUSION

Children with IDA have increased endogenous thrombin production in platelet-poor plasma and a tendency for hypercoagulability. These changes are reversible, and the ETP values become similar to those of healthy children 1 month after iron replacement.

Thiol / disulfide balance and oxidative stress parameters in pediatric patients diagnosed with acute and chronic idiopathic thrombocytopenic purpura

BACKGROUND

Changes in oxidative stress and thiol / disulfide balance are thought to play a role in the pathogenesis of idiopathic thrombocytopenic purpura (ITP). Our study investigates total oxidant level (TOS), total antioxidant level (TAS), oxidative stress index (OSI) levels and thiol / disulfide balance in pediatric patients with acute and chronic ITP.

METHODS

Thirty four patients with acute ITP, eighteen patients with chronic ITP and thirty three healthy children (control) were included. TOS, TAS, OSI, thiol / disulfide balance were analyzed.

RESULTS

In acute ITP, TAS levels were lower than chronic ITP and control, TOS and OSI levels were higher than control, and native thiol level was lower than chronic ITP (p < 0.05). In acute ITP; disulfide level, disulfide / native thiol and disulfide / total thiol ratios were higher than chronic ITP and control, and native thiol / total thiol ratio was lower than chronic ITP and control group (p = 0.038, p = 0.018, respectively). TOS and OSI levels of the chronic ITP were higher than the control group (p < 0.05).

CONCLUSIONS

The results of this study have shown that oxidative stress increases in children with acute ITP and chronic ITP, that thiol / disulfide balance is disrupted in favor of disulfide in acute ITP, and that thiol / disulfide balance isn`t disrupted in chronic ITP patients whose platelet count is close to normal and who don`t require treatment.

Cerebral sinovenous thrombosis in children: clinical presentation, locations, and acquired and inherited prothrombotic risk factors

BACKGROUND

Cerebral sinovenous thrombosis (CSVT) in children is a rare and life-threatening cerebrovascular disease. Hence, we evaluated its clinical presentations, inherited and acquired prothrombotic risk factors along with the accompanying diseases, the thrombosis locations as well as the outcomes of anticoagulant therapy in children with CSVT.

METHODS

The medical records of pediatric CSVT patients treated between January 2011 and September 2018 were analyzed retrospectively.

RESULTS

The study included 29 children, 15 boys (51.7%) and 14 girls (48.3%), with the median age being 11 years (range:3 days-17 years). The most commonly presented complaint in neonates was seizures and in the non-neonatal age groups was a headache. Also, at least one acquired and/or inherited thrombophilic risk factor was identified in 89.7% of the patients. The most commonly acquired prothrombotic risk factors along with the accompanying diseases included infections, central venous catheter, and dehydration, while the most commonly inherited thrombophilic risk factors included heterozygous factor-V Leiden mutation and elevated lipoprotein (a). The most common thrombosis location was found to be the transverse sinus. Also, none of the patients died due to the thrombotic episode. Complications included epilepsy in five patients, hydrocephalus in one patient, and intracranial hypertension in another patient.

CONCLUSIONS

Clinicians need to be well aware of the inherited and acquired prothrombotic risk factors in CSVT. It should also be kept in mind that at-risk patients may also present with nonspecific signs and symptoms with no apparent neurological manifestation. The risk of acute complications and long-term sequelae can be substantially reduced if diagnosed early and initiated with appropriate treatment at the early stages.

Hepatitis-Associated Aplastic Anemia: Etiology, Clinical Characteristics and Outcome

Hepatitis-associated aplastic anemia (HAA) is a form of acquired aplastic anemia (AA) in which bone marrow failure develops after an acute attack of hepatitis. Bone marrow failure leading to AA is generally severe in cases of HAA and fatal if left untreated. This retrospective multicenter study investigated clinical and laboratory characteristics, possible causes, treatment, and outcome of HAA in children. Twenty patients from 8 centers were included in the study. Aspartate aminotransferase and alanine aminotransferase were <3 to 5×upper limit of normal (ULN) in 2 patients, <5 to 10×ULN in 2 patients, and >10×ULN in 16 patients. Acute liver failure developed in 5 (29%) patients. Pancytopenia was simultaneously present in 6 of 20 (30%) patients. Eleven of the 20 patients (55%) were alive, in remission and transfusion free. Those who were alive either had undergone hematopoietic stem cell transplantation and/or immunosuppressive treatment, except 1 patient who had received no treatment. Patients with the diagnosis of acute hepatitis should be evaluated and followed up carefully for presence of cytopenia, so that definitive treatment of AA can be initiated in a timely and appropriate manner when needed.

Relationship between oxidant-antioxidant status and hypercoagulobility indices in children with iron deficiency anaemia

Oxidative stress is a potential mechanism involved in the pathogenesis of iron deficiency anaemia (IDA). Although a tendency for hypercoagulability has been reported in IDA, its underlying mechanism is yet to be elucidated. This study investigated the probable relationship between oxidative stress and hypercoagulability in children with IDA. This study included 57 children diagnosed with IDA (IDA group) between October 2016 and October 2017 in addition to 48 healthy children (control group). The maximum clot firmness (MCF) index, and clot formation time (CFT) index, which are indicators of hypercoagulability in rotational thromboelastometry assays [intrinsic TEM (INTEM) and extrinsic TEM (EXTEM)] derived from our previous study, were recorded. Total oxidant status (TOS), total antioxidant capacity (TAC) and oxidative stress index (OSI) were analysed from serum samples of the individuals. In IDA group, OSI and TOS levels were higher and TAC level was lower compared to the control group (P < 0.001, for all). The EXTEM and INTEM MCF in the IDA group was higher than in the control group, while the INTEM CFT was lower than in the control group (P < 0.001, P < 0.001, P < 0.05, published data).TOS and OSI had a negative correlation with INTEM CFT (r:-0.361, P < 0.001 and r:-0.333, P = 0.001) and a positive correlation with INTEM MCF (r:+0.420, P < 0.001 and r:+0.367, P < 0.001) and EXTEM MCF (r:+0.476, P < 0.001 and r:+0.403, P < 0.001). However, TAC demonstrated no correlation with CFT and MCF index. The oxidant-antioxidant balance is disrupted in favour of oxidative stress in children with IDA. In addition, TOS and OSI, which are parameters of oxidative stress, are correlated with CFT and MCF indices. Oxidative stress appears to be an important factor for the development of tendency to hypercoagulability in IDA.

Whole Blood miR-210, miR-122, miR-223 Expression Levels and Their Relationship With Iron Status Parameters and Hypercoagulability Indices in Children With Iron Deficiency Anemia

MicroRNAs have the potential to regulate systemic and cellular iron homeostasis at multiple points. In iron deficiency anemia (IDA), hypoxia, platelet reactivity, and potentially microRNAs play a role in the development of hypercoagulability. A total of 57 children diagnosed with IDA between October 2016 and October 2017 and 48 healthy children were included in this cross-sectional study. Blood count parameters, serum iron, transferrin saturation, ferritin level, maximum clot firmness (MCF), and clot formation time index, which are indicators of hypercoagulability in rotational thromboelastometry test, of the IDA and control groups obtained in our previous study were recorded. miR-210, miR-122, and miR-223 levels were analyzed. There was no difference in the miR-210, miR-122, and miR-223 levels between the IDA and control groups. Patients with hemoglobin (Hb) <8 g/dL had higher miR-210 levels than patients with Hb>8 g/dL (P<0.05). There was a negative correlation between miR-210 and Hb and ferritin levels, a positive correlation between miR-122 and ferritin levels, and a negative correlation between miR-223 and MCF index. In IDA, there is a close relationship between the severity of anemia and miR-210, and miR-210 expression is slightly increased in those with severe anemia. miR-210 and miR-122 collectively play a role in maintaining the iron balance. The correlation between miR-223, a platelet function regulator, and the MCF index, suggested that miR-223 has a role in the development of hypercoagulability in IDA.

Paediatric Agranulocytosis Associated with Metamizole Treatment

PURPOSE

Metamizole, which has antipyretic and pain-relieving properties, is generally used to treat fever in children who do not respond to paracetamol treatment. The most remarkable side effect of metamizole is that it causes myelotoxicity independently of dose. In this study, we aimed to present the clinical features of paediatric patients who developed agranulocytosis after the use of metamizole and draw attention to this side effect.

METHODS

The patients who were admitted to Eskişehir Osmangazi University Faculty of Medicine Hospital, Pediatric Infectious Diseases and Pediatric Hematology Service, between January 1, 2015, and December 31, 2018, with a diagnosis of secondary agranulocytosis to metamizole use were examined retrospectively.

RESULTS

In all, 12 patients were included in the study; oral metamizole was used in these patients for fever reduction. The mean absolute neutrophil count was 225/mm³ ± 226 (0-600/mm³) at admission, and the neutrophil value of 11 patients was < 500/mm³. The mean length of hospitalisation of the patients was 9.92 ± 8 (3-28) days. Eight patients received intravenous antibiotic therapy and four patients received at least one of the following treatments: intravenous immunoglobulin, granulocyte colony-stimulating factor and methylprednisolone. Bone marrow aspiration examination showed neutrophil/band maturation delaying in the myeloid series with normocellular bone marrow in three patients. Hypocellularity in the bone marrow and decrease in myeloid precursors were observed in three patients. There were no fatal cases.

CONCLUSION

The development of agranulocytosis after the use of metamizole causes long-term hospitalisation and may require the use of medications in treatment management. Considering the availability of alternative options to treat fever and pain, and given the side-effect profile of metamizole, it should not be the preferred, first-line antipyretic treatment in children.

A Case of Congenital Hepatoblastoma Coexisting with Pulmonary Hypertension

Hepatoblastoma (HBL) is the most frequently detected malignant tumor of the liver in childhood. HBLs detected antenatally or up to 3 months after birth are considered congenital HBLs. We report a five-day-old female infant in whom a hepatic mass was detected at 20 weeks' gestation. At birth (36 weeks), the hepatic mass measured 12x6 cm, and she had respiratory distress. Pulmonary hypertension (PHT) was detected on echocardiographic evaluation. Despite dual medical therapy, her PHT did not improve. Histologically, the biopsy demonstrated a mixed epithelial-mesenchymal HBL with predominance of fetal morphology in the epithelial component. Chemotherapy was initiated on postnatal day 15; however, the baby died of respiratory failure on postnatal day 23. Conclusion: HBL is an embryonal tumor which can develop early in the intrauterine period. Although the mechanism is not known, it may cause PHT which would affect the prognosis negatively.

Outcomes of Eltrombopag Treatment and Development of Iron Deficiency in Children with Immune Thrombocytopenia in Turkey

Objective

Immune thrombocytopenia (ITP) is a rare autoimmune disease and hematologic disorder characterized by reduced platelet counts that can result in significant symptoms, such as bleeding, bruising, epistaxis, or petechiae. The thrombopoietin receptor agonist eltrombopag (EPAG) is a second-line agent used to treat chronic ITP purpura in adults and children.

Materials and Methods

The present retrospective study evaluated the efficacy, safety, and side effects of EPAG treatment in pediatric patients with acute refractory and chronic immune thrombocytopenia, particularly focusing on iron-deficiency anemia.

Results

The diagnosis was chronic ITP in 89 patients and acute refractory ITP in 16 patients. The mean age of patients was 9.5±4.5 years (minimum-maximum: 1.2-18 years) at the beginning of EPAG treatment. The overall response rate was 74.3% (n=78). The mean time for platelet count of ≥50x109/L was 11.6±8 weeks (range: 1-34 weeks). The treatment was stopped for 27 patients (25.7%) at an average of 6.8±9 months (range: 1-38 months). The reason for discontinuation was lack of response in 18 patients, nonadherence in 4 patients, and hepatotoxicity in 2 patients. Response to treatment continued for an average of 4 months after cessation of EPAG in 3 patients.

Conclusion

Results of the current study imply that EPAG is an effective therapeutic option in pediatric patients with acute refractory and chronic ITP. However, patients must be closely monitored for response and side effects during treatment, and especially for iron deficiency.

Myocardial functions, blood pressure changes, and arterial stiffness in children with severe hemophilia A

INTRODUCTION

Prolonging the life span of patients with hemophilia has led to the emergence of comorbidities. Cardiovascular diseases are one of the important causes of mortality in patients with hemophilia. This study investigated the myocardial functions, blood pressure changes, arterial stiffness, and risk factors associated with cardiovascular diseases in children with hemophilia.

MATERIAL AND METHODS

In total, 17 children with severe hemophilia A and 23 healthy children were included in the study. Myocardial functions were evaluated using standard and tissue Doppler echocardiography. Peripheral and central blood pressure measurements were performed, and arterial stiffness was evaluated. Carotid intima-media thicknesses (CIMT) serum glucose, insulin, insulin resistance index, and lipoprotein levels were measured.

RESULTS

There were no differences between the two groups in terms of age, and biochemical parameters (P > 0.05). The HDL-C levels in the hemophilia group were lower than those in the control group (P < 0.05). Five of the patients had insulin resistance (29.4%), whereas four had low HDL-C levels (23.5%). There were no differences between the groups in terms of the CIMT, peripheral blood pressure, and central systolic blood pressure (P > 0.05). In the hemophilia group, central diastolic blood pressure (cDBP), arterial stiffness, and myocardial performance index were higher (P < 0.05, P = 0.01, P < 0.01), whereas the ejection time was shorter than in the control group (P < 0.05).

CONCLUSIONS

Compared with the control group, there is an onset of arterial stiffness, cDBP values tend to increase, and serum HDL-C levels are lower in the hemophilia group. Moreover, myocardial systolic functions demonstrate a deterioration that becomes more prominent with the increase in arterial stiffness.

The predictive value of procalcitonin, C-reactive protein, presepsin, and soluble-triggering receptor expressed on myeloid cell levels in bloodstream infections in pediatric patients with febrile neutropenia

Özdemir ZC, Düzenli-Kar Y, Canik A, Küskü-Kiraz Z, Özen H, Bör Ö. The predictive value of procalcitonin, C-reactive protein, presepsin, and soluble-triggering receptor expressed on myeloid cell levels in bloodstream infections in pediatric patients with febrile neutropenia. Turk J Pediatr 2019; 61: 359-367. The present study investigates the predictive value of procalcitonin (PCT), C-reactive protein (CRP), presepsin (PRE-SEP) and soluble-triggering receptor, as expressed on myeloid cells (sTREM-1) levels in bloodstream infections in pediatric patients with febrile neutropenia. A total of 47 episodes of febrile neutropenia that developed in 30 children with malignancy were analyzed in this study, while the control group comprised 27 children who had undergone chemotherapy for malignancy (completed ≥2 years ago) without neutropenia, fever or drug use. Median PCT, CRP, PRE-SEP and sTREM-1 levels on admission were found to be significantly higher in the patient group than in the control group, while in the blood cultures, the microbiological agent was isolated in 13 (27.7%) of the 47 episodes. Median PCT and CRP levels on days 1, 2 and 7 were higher in the blood culture-positive episodes than in the blood culture-negative episodes. There was no significant difference in the PRE-SEP and sTREM-1 levels on days 1, 2 and 7 between the blood culture-positive and blood culture-negative episodes. The results of the study suggest that PRESEP and sTREM-1 are at measurable levels upon admission in children with febrile neutropenia, but that these markers may not be appropriate for the predicting of bloodstream infections, although CRP and PCT levels within the first 24 hours may serve as a guide for clinicians.

Infantile hemangioma: Efficacy of low-dose propranolol and of intralesional bleomycin injection for propranolol non-response

BACKGROUND

Infantile hemangioma (IH) is the most common form of benign childhood vascular tumor. Most resolve spontaneously, but treatment is recommended in patients who develop complication. Propranolol is recommended as the first-line therapy, while the treatment in the case of non-response to first-line therapy depends on the clinical experiences of each center. The aim of this study was to investigate the efficacy of low-dose propranolol in the treatment of IH, and the outcomes of percutaneous intralesional bleomycin injection (IBI) in patients unresponsive to propranolol.

METHODS

Medical records of 104 children diagnosed with IH between June 2014 and June 2017 were reviewed retrospectively.

RESULTS

Median patient age was 6 months (range, 3-12 months). Forty-five patients (43.3%) received therapy: 18 (40%) for cosmetic problems and 27 (60%) for lesion-related complications. The most common complications were hemorrhage (15.6%) and impairment in visual function (15.6%). All of the patients received propranolol 1 mg/kg/day as the first-line therapy. Response to treatment was excellent in 35 patients, good in four and poor in one, while five patients did not respond to therapy. The five unresponsive patients received percutaneous IBI at 0.3-0.5 mg/kg/dose as second-line therapy. The response to treatment was excellent in four patients, good in one.

CONCLUSIONS

The majority of IH resolved spontaneously. In the patients who required treatment, low-dose propranolol was successful in most, and IBI was effective and safe in the remaining five patients who did not respond to propranolol.

Hemophagocytic Lymphohystiocytosis Associated With Type Ia Glycogen Storage Disease

BACKGROUND

Hemophagocytic lymphohystiocytosis (HLH) is characterized by fever, splenomegaly, pancytopenia, and elevated levels of triglycerides and ferritin. These signs and symptoms are common to other metabolic diseases.

OBSERVATION

A 5-month-old female infant, who presented with fever, respiratory distress, massive hepatomegaly, and bicytopenia, was diagnosed as having HLH and chemotherapy was initiated. The patient was negative for familial HLH gene mutations. Respiratory distress and laboratory findings improved rapidly after starting chemotherapy. However, there was no improvement in the massive hepatomegaly and she experienced hypoglycemic episodes. In addition, her family history included a cousin with glycogen storage disease (GSD). On the basis of the findings, the patient was diagnosed as having type Ia GSD. There are no previous reports of HLH secondary to GSD type Ia in the literature.

CONCLUSIONS

Congenital metabolic diseases should be considered in the differential diagnosis of children with HLH.

The Frequency of Metabolic Syndrome and Serum Osteopontin Levels in Survivors of Childhood Acute Lymphoblastic Leukemia

PURPOSE

Metabolic syndrome (MetS) and obesity have increasingly been reported in survivors of childhood cancer. Osteopontin (OPN) is primarily synthesized in adipose tissue and is thought to have a role in obesity and the development of insulin resistance (IR). The aim of this study was to investigate the frequency of MetS in survivors of acute lymphoblastic leukemia (ALL) and to establish the relationship between serum OPN levels and anthropometric measurements and glucose metabolism.

METHODS

A total 50 survivors of ALL (median age: 10.5 years; post-treatment interval 4.54 ± 2.48 years), and 20 healthy children (median age: 11 years) were included in the study. Anthropometric measurements were taken, and serum glucose, insulin, homeostasis model assessment and IR index (HOMA-IR index), lipoprotein, thyroid hormone levels, and OPN levels were measured.

RESULTS

Twenty-one (42%) survivors were overweight/obese, 2 (5.1%) survivors had MetS, 7 (14%) survivors had IR, and 19 (38%) survivors had dyslipidemia. Fasting insulin levels and HOMA-IR of the overweight/obese survivors were significantly higher than those of the normal-weight survivors (p < 0.05 and p < 0.01) and control group (p < 0.01 and p < 0.01). The serum OPN level was significantly lower in the overweight/obese survivor than in the normal-weight survivor and control group (37.42 ng/mL [range, 27.32-62.07], 69.02 ng/mL [range, 40.29-88.21], and 85.7 ng/mL [range 67.7-102.3]; p < 0.01, p < 0.001, respectively). Serum OPN levels were inversely correlated with anthropometric measurements and HOMA-IR index in all the subjects.

CONCLUSION

Our results showed that obesity and IR are associated with decreased serum OPN levels in childhood survivors of ALL.

Neurocognitive Consequences of Childhood Leukemia and Its Treatment

As survival rates have improved in pediatric patients with leukemia, late side effects from chemotherapeutics and radiotherapy have become important considerations. We investigated these side effects and evaluated their impact on neurocognitive functions. The observational study included 68 patients with acute leukemia who were treated at Eskisehir Osmangazi University Medical Faculty. The study also included 62 of the patients' closest age siblings as a control group. Demographic and clinical data, chemotherapy protocol, use of radiotherapy were recorded, neurological and ophthalmological examinations, cranial imaging, electroencephalography, visual evoked potential, and hearing investigations were performed, and neurocognitive functions were evaluated. At least one or more late effects detected by a neurologic abnormality on physical exam, cranial magnetic resonance imaging, neurological tests, or neurocognitive tests was significantly more likely in the patient group (82.4%) compared to the control group (29%, p < 0.001). A higher rate (82.4%) of delayed neurological and cognitive problems occurred in children who received radiotherapy, intrathecal and/or systemic chemotherapy during leukemia treatment compared to age-matched siblings. Patients being treated for leukemia should be periodically evaluated for treatment-related side effects. Prophylactic interventions such cognitive training and maintenance of academic growth may offer the best hope of preventing late effects.

Evaluation of febrile neutropenic attacks of pediatric hematology-oncology patients

Aim

Febrile neutropenia is an important cause of mortality and morbidity in hematology-oncology patients undergoing chemotherapy. The objective of this study was to evaluate febrile neutropenic episodes in children with malignancy.

Material and Methods

Sixty-eight children who received chemotherapy for malignancy between 2010 and 2015 were retrospectively reviewed. The demographic characteristics, laboratory data, infection foci, and frequency of microorganisms grown in culture were examined. Also, the frequency of febrile neutropenic attacks was investigated according to the chemotherapy periods.

Results

Of the total 200 episodes, 81 (40.5%) were clinically documented, and 73 (36.5%) were microbiologically documented infections. Fever of unknown origin was observed in 46 (23%) episodes. The most frequently clinically documented focus were mucositis (33.4%) and pneumonia (24.7%). Blood culture was positive in 55 (75.3%) episodes of microbiologically documented infections. The most commonly isolated microorganisms in blood culture were Gram-negative bacteria (47.2%). C-reactive protein levels in microbiologically documented infections were higher than in clinically documented infections, and fever of unknown origin (p<0.05, for both). The most common underlying malignancy was acute lymphoblastic leukemia (73.5%). The highest proportions (34.6%) of febrile neutropenic episodes were observed during the reinduction period for these children. Nine (13.2%) children died of neutropenic sepsis.

Conclusions

Febrile neutropenia continues to be an important cause of mortality in pediatric patients with malignancy. C-reactive protein levels may be an indicator for predicting bacterial infection in children with febrile neutropenia without apparent focus. The most frequently isolated agents in our center were Gram-negative microorganisms. Determining the microbial flora of each center may be beneficial to improving survival rates.

Plasmapheresis in a child with cold antibody autoimmune hemolytic anemia: case report

Autoimmune hemolytic anemia is a picture of hemolysis which is caused by autoantibodies against red blood cell surface antigens. It is classified as primary, secondary or warm and cold autoimmune hemolytic anemia according to the temperature at which antibodies react. It is usually an acute and self-limiting condition. Here, we present a three-year-old male patient who presented with malaise, paleness, and dark-colored urine. His hemoglobin level was 5.8 g/dL, and increased indirect bilirubin and lactate dehydrogenase levels and decreased haptoglobulin and reticulocyte levels were noted. A direct Coombs test was positive using anti-C3. Four erythrocyte suspension transfusions were given because the anemia was life-threatening. High-dose steroids (30 mg/kg/ day, methylprednisolone) and intravenous immunoglobulin (1 g/kg/day, two days) treatments were unresponsive. Plasmapheresis was performed and no further transfusions were needed after plasmapheresis. Plasmapheresis treatment can be effective in children with cold type autoimmune hemolytic anemia.

A National Registry of Thalassemia in Turkey: Demographic and Disease Characteristics of Patients, Achievements, and Challenges in Prevention

Objective:

The Turkish Society of Pediatric Hematology set up a National Hemoglobinopathy Registry to demonstrate the demographic and disease characteristics of patients and assess the efficacy of a hemoglobinopathy control program (HCP) over 10 years in Turkey.

Materials and Methods:

A total of 2046 patients from 27 thalassemia centers were registered, of which 1988 were eligible for analysis. This cohort mainly comprised patients with β-thalassemia major (n=1658, 83.4%) and intermedia (n=215, 10.8%).

Results:

The majority of patients were from the coastal areas of Turkey. The high number of patients in Southeastern Anatolia was due to that area having the highest rates of consanguineous marriage and fertility. The most common 11 mutations represented 90% of all β-thalassemia alleles and 47% of those were IVS1-110(G->A) mutations. The probability of undergoing splenectomy within the first 10 years of life was 20%, a rate unchanged since the 1980s. Iron chelators were administered as monotherapy regimens in 95% of patients and deferasirox was prescribed in 81.3% of those cases. Deferasirox administration was the highest (93.6%) in patients aged <10 years. Of the thalassemia major patients, 5.8% had match-related hemopoietic stem cell transplantation with a success rate of 77%. Cardiac disease was detected as a major cause of death and did not show a decreasing trend in 5-year cohorts since 1999.

Conclusion:

While the HCP has been implemented since 2003, the affected births have shown a consistent decrease only after 2009, being at lowest 34 cases per year. This program failure resulted from a lack of premarital screening in the majority of cases. Additional problems were unawareness of the risk and misinformation of the at-risk couples. In addition, prenatal diagnosis was either not offered to or was not accepted by the at-risk families. This study indicated that a continuous effort is needed for optimizing the management of thalassemia and the development of strategies is essential for further achievements in the HCP in Turkey.

Fatal course of Saprochaete capitata fungemia in children with acute lymphoblastic leukemia

Saprochaete capitata (S. capitata) is a very rare fungal pathogen that causes disseminated opportunistic infections in patients with hematologic malignancies. Fever resistant to broad-spectrum antibiotic and antifungal treatment is common in the presence of fungemia during the period of profound neutropenia. We describe three cases of leukemic children who died from S. capitata fungemia following a first febrile neutropenic episode after the induction of chemotherapy. S. capitata fungemia is an emergent infection associated with high mortality and low susceptibility to fluconazole and echinocandins. Awareness of this emergent infection is needed to ensure that it can be properly treated.

Thromboelastogram as a Tool to Predict Hypercoagulability in Children With Cystic Fibrosis

Increased thrombophilic tendency in patients with cystic fibrosis (CF) has recently been reported. The determinants of thrombosis in children with CF remain largely unknown. Our aim in this study was to evaluate the thromboelastography (TEG) profile of children with CF through ROTEM (whole blood rotation thromboelastometry). Nineteen patients with CF and 20 controls were included in the study. Whole blood count, prothrombin time, activated prothrombin time, fibrinogen, d-dimer levels, and ROTEM assays (INTEM, EXTEM) were performed. Clotting time, clot formation time (CFT), and maximum clot firmness (MCF) were determined by INTEM and EXTEM analysis. In INTEM assay, MCF ( P = .001) value was significantly increased and CFT ( P = .031) value was decreased in patients with CF compared with those of the control group. In the EXTEM assay, there was a similar significant increase in MCF ( P = .023) value in patients with CF compared with that of the control group. There was a significant positive correlation between fibrinogen levels and MCF in EXTEM ( r = .72) and INTEM ( r = .76) assays, whereas there was a negative correlation with CFT in EXTEM ( r = -.61) and INTEM ( r = -.67). The results of our study indicated that TEG profiles in patients with CF were more hypercoagulable compared with those of the control group.

The frequency of hepatotoxicity and myelotoxicity in leukemic children with different high doses of methotrexate

Background and objectives

Methotrexate (MTX) is a chemotherapeutic agent that functions as a folic acid antagonist. The frequency of high dose methotrexate (HDMTX)-associated toxicity is variable. In this study, we investigated the frequency of myelotoxicity and hepatotoxicity 7 days after HDMTX infusion.

Patients and methods

This study included children diagnosed with acute lymphoblastic leukemia (ALL) between January 2010 and April 2015. The patient blood counts and biochemical parameters measured before and after 7 days of HDMTX infusion were retrospectively recorded. We assessed HDMTX infusions for 48 children. The number of patients and drug doses included the following: 17 children receiving 1 g/m² (68 infusions), 14 children receiving 2 g/m² (56 infusions), and 17 children receiving 5 g/m² (68 infusions). The classification of toxicity was made based on the Common Terminology Criteria for Adverse Events (CTCAE) 2010 criteria. Myelotoxicity was defined as a hemoglobin level <10 g/L and absolute neutrophil count <1 × 10⁹/L or platelet count <75 × 10⁹/L. The presence of transaminase levels ≥5 times the upper limit was considered to be hepatotoxicity grade ≥3. The MTX levels at 42 h in patients with and without toxicity were compared to evaluate the correlation between MTX levels, hematologic parameters, and transaminase levels.

Results

Myelotoxicity was observed in 35.2%, 37.5%, and 33.8% of the infusions, and hepatotoxicity grade ≥3 was detected in 13.2%, 12.5%, and 11.7% of the infusions in patients receiving 1, 2 and 5 g/m² HDMTX after 7 days, respectively. There was no statistically significant difference between MTX levels at 42 h in patients with and without toxicity (P > .05, for all). There was no correlation between hematologic parameters and transaminase levels and MTX levels at 42 h.

Conclusion

Hematologic toxicity was the most common toxicity observed. The data indicate the hematologic toxicity increased after repeated cycles in patients receiving 5 g/m². However, the hepatic toxicity decreased with additional cycles. Our results show the level of MTX at 42 h is not effective to identify toxicity.

Hemi-meningitis with hemophagocytic lymphohistiocytosis

Hemophagocytic lymphohistiocytosis (HLH) is a rare lymphoproliferative disorder. HLH may occur as a complication of Epstein-Barr virus (EBV), particularly in patients with immunodeficiencies. Herein, we describe a 16-year-old girl with neurological complications associated EBV-induced HLH. Her cerebral magnetic resonance imaging (MRI) showed contrast-enhanced axial T1-weighted images with enhancement of meningeal surface in the right hemisphere that was consistent with right hemi-meningitis. Hydrocephalus, dilated subdural spaces, delayed myelination, edema, diffuse parenchymal atrophy, calcifications, diffuse/patchy white matter abnormalities have all been previously described with HLH. To the best of our knowledge, this is the first case of hemi-meningitis associated with HLH. We suggest that clinicians should consider HLH with vascular disorders when they determine unilateral meningitis on a brain MRI.

Use of herbs or vitamin/mineral/nutrient supplements by pediatric oncology patients

Use of complementary and alternative medicine (CAM) is widespread and increasing. We sought to study the frequency and factors affecting of its use in children with cancer. We designed a questionnaire that was administered to the parents of children between September 2013 and March 2014. A total of 74 patients were enrolled into the study. Fifty patients (67.5%) had used one or more than one type of herbs or vitamin/mineral/nutrient. The most commonly used CAM treatment was grape molasses (36.6%). The main source of information to families was the internet. No correlation found between the use of CAM and parents' education status, the level of income, socioeconomic status, chemotherapy treatment. Patients with cancer highly tended to use CAM treatment without informing healthcare professionals. The integration of complementary methods to the conventional treatments is interesting and seem to respond to the needs of patients allowing a more comprehensive approach to care.

Ptosis during hematologic malignancy in children

Neurological symptoms such as ptosis may develop due to either chemotherapeutic agents or involvement of the central nervous system (CNS) during hematologic malignancy. It is difficult to make this distinction according to clinical symptoms and magnetic resonance imaging findings. If the neurologic symptoms are increased, it is a warning of CNS involvement. Herein are described the clinical and neuroimaging features of three patients with hematologic malignancy who presented with ptosis.

Nonconvulsive status epilepticus due to drug induced neurotoxicity in chronically ill children

Nonconvulsive status epilepticus (NCSE) is a specific form of status epilepticus and is defined as epileptic activity on an EEG without seizures and as an alteration in mental status lasting more than 30 min. NCSE may be caused by drugs, cerebrovascular events, metabolic disorders or toxins. Herein, we present four cases of patients with drug-induced NCSE who were chronically ill due to renal failure or childhood leukemia. NCSE should be suspected in patients with an altered mental status without clinical seizures who are being treated with multiple drugs.