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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Familial Hemophagocytic Lymphohistiocytosis With Heterozygous STX11 and Homozygous UNC13D Mutations Diagnosed in the Neonatal Period

Patients with primary hemophagocytic lymphohistiocytosis may present with different mutations and phenotypic findings. It is usually presented as case reports because of its rare occurrence. Here, we discuss a case diagnosed with familial hemophagocytic lymphohistiocytosis 3, that presented in the neonatal period and was detected to have homozygous UNC13D and heterozygous STX11 mutations.

Acquired noncaustic esophageal strictures in children

BACKGROUND

Esophageal stricture (ES) is an uncommon clinic entity in pediatrics that may be congenital or acquired in childhood. Acquired noncaustic ES is very rare, and clinical features of affected patients are unknown.

PURPOSE

We aimed to evaluate the clinical findings, and outcomes of patients with acquired noncaustic ES to aid physicians in the early referral of patients to gastroenterologists.

METHODS

The medical data of patients with acquired noncaustic ES who were followed in our gastroenterology clinic between January 2009 and December 2019 were reviewed.

RESULTS

Acquired noncaustic ES was found in 12 of the 4,950 patients (0.24%) who underwent endoscopy during the study period. The main symptoms were dysphagia (58.3%), vomiting (33.3%), and chronic anemia (8.3%). Chronic malnutrition and underweight were found in 66.6% of the patients. The most common etiological factors were radiotherapy, peptic reflux, and achalasia (16.6%, each), while chemotherapy, squamous-cell carcinoma (SC) of the esophagus, eosinophilic esophagitis (EoE), esophageal web, epidermolysis bullosa, and esophageal diverticulum (8.2%, each) were the other etiological factors. Patients with EoE underwent endoscopic bougie dilation in addition to steroid use and elimination diet. Patients with epidermolysis bullosa and esophageal web underwent bougie dilation. Patients with peptic reflux-related ES were initially put on antireflux therapy, but during follow-up, one patient required esophageal replacement with colonic interposition. Patients with radiotherapy-related ES recovered with medical therapy. The patient with initially underwent surgical gastrostomy and tumoral mass excision. The patient then received chemotherapy and radiotherapy and underwent jejunal interposition. Patients with achalasia underwent surgical esophagomyotomy.

CONCLUSION

The presence of solid dysphagia, malnutrition, and an associated disease may alert physicians to the presence of ES.

Augmented mitochondrial cytochrome c oxidase activity in children with iron deficiency: a tandem between iron and copper?

INTRODUCTION

Dyshomeostasis of essential trace elements including iron and copper plays a key role in the pathogenesis of a myriad of serious conditions including iron deficiency (ID) anemia, in which impaired cellular energy metabolism is prominent. Although experimental studies documented decreased activity of cytochrome c oxidase (CytOx) in ID, there are not enough clinical data. The present study was conducted to determine serum copper levels and activity of mitochondrial CytOx in isolated lymphocytes of patients with iron deficiency.

MATERIAL AND METHODS

A total of 210 cases (2-17 years) were included in this prospective study. Serum iron and copper levels were measured. According to the serum iron levels, patients were allocated to iron deficient (ID, n = 70) and iron deficiency anemia (IDA, n = 70) groups, and iron-sufficient participants were allocated to the control group (n = 70). Activity of CytOx in the circulating lymphocytes was colorimetrically measured and compared with the controls.

RESULTS

The CytOx activity was significantly higher in the IDA (2.9 ±1.2 mOD/min, n = 62) group compared to the control group (2.4 ±1.3 mOD/min, n = 68, p < 0.001). Interestingly, serum copper levels were significantly higher in both the ID (106.9 ±55.5 μg/dl, n = 64, p = 0.0001) and IDA (115.1 ±50.2 μg/dl, n = 59, p = 0.0001) groups than the control group (72.1 ±46.7 μg/dl, n = 69).

CONCLUSIONS

Higher serum copper levels in patients with IDA implicate co-operative interaction between these trace elements. The elevated CytOx activity in patients with IDA is probably secondary to the normal/elevated serum copper levels.

Assessment of Palliative Care in Lung Cancer in Turkey

OBJECTIVE

To investigate the symptoms of lung cancer in Turkey and to evaluate approaches to alleviate these symptoms.

SUBJECTS AND METHODS

This study included 1,245 lung cancer patients from 26 centers in Turkey. Demographic characteristics as well as information regarding the disease and treatments were obtained from medical records and patient interviews. Symptoms were evaluated using the Edmonton Symptom Assessment Scale (ESAS) and were graded on a scale between 0 and 10 points. Data were compared using the χ2, Student t, and Mann-Whitney U tests. Potential predictors of symptoms were analyzed using logistic regression analysis.

RESULTS

The most common symptom was tiredness (n = 1,002; 82.1%), followed by dyspnea (n = 845; 69.3%), appetite loss (n = 801; 65.7%), pain (n = 798; 65.4%), drowsiness (n = 742; 60.8%), anxiety (n = 704; 57.7%), depression (n = 623; 51.1%), and nausea (n = 557; 45.5%). Of the 1,245 patients, 590 (48.4%) had difficulty in initiating or maintaining sleep. The symptoms were more severe in stages III and IV. Logistic regression analysis indicated a clear association between demographic characteristics and symptom distress, as well as between symptom distress (except nausea) and well-being. Overall, 804 (65.4%) patients used analgesics, 630 (51.5%) received treatment for dyspnea, 242 (19.8%) used enteral/parenteral nutrition, 132 (10.8%) used appetite stimulants, and 129 (10.6%) used anxiolytics/antidepressants. Of the 799 patients who received analgesics, 173 (21.7%) reported that their symptoms were under control, and also those on other various treatment modalities (dyspnea: 78/627 [12.4%], appetite stimulant: 25/132 [18.9%], and anxiolytics/antidepressants: 25/129 [19.4%]) reported that their symptoms were controlled.

CONCLUSION

In this study, the symptoms progressed and became more severe in the advanced stages of lung cancer, and palliative treatment was insufficient in most of the patients in Turkey.

Positive correlation between insulin resistance and iron overload-induced oxidative stress in patients with fanconi anemia (FA)- and non-FA-related bone marrow failure: The results of a multicenter study

This study investigated the relationship between DNA, protein, and lipid oxidations and insulin resistance in patients with Fanconi anemia (FA)- and non-FA-related bone marrow failure. Sixteen patients with FA, 7 non-FA-related aplastic anemia, and 10 controls were included in the study. Fasting blood glucose, simultaneous insulin, hepcidin, ferritin, 8-hydroxy deoxyguanosine (8-OHdG), protein carbonyls, malondialdehyde (MDA), and homeostatic model assessment-insulin resistance (HOMA-IR) were investigated in the patients and controls. Diepoxybutane test-positive (DEB+) patients were diagnosed with FA, whereas DEB-patients were diagnosed as non-FA. 8-OHdG levels in both FA and non-FA patients were significantly higher than those in the controls (P = .001 and P = .005, respectively). Serum ferritin levels were also higher in FA and non-FA patients than in the controls (P = .0001 and P = .005, respectively). Insulin resistance (IR) was significantly higher in FA patients than in non-FA patients and controls (P = .005 and P = .015, respectively). Significant differences were observed between 8-OHdG, ferritin, and MDA levels in patients with or without IR (P = .009, P = .001, and P = .013, respectively). Moderate and strong relations of 44% and 85% were determined between IR and ferritin levels in patients with FA or non-FA (P = .08 and P = .014, respectively). FA and non-FA patients exhibited a tendency to IR. IR was related to ferritin levels, and ferritin levels were also correlated with oxidative stress. These findings suggest that the increased rate of IR in patients with FA and non-FA may derive from increased oxidative stress, which may in turn be due to elevated serum ferritin levels.

THE RELATIONSHIP BETWEEN CONGENITAL HEART DEFECTS AND e-NOS GENE IN DOWN SYNDROME

The aim of the study was to compare the effects of three eNOS gene polymorphisms associated with congenital heart defects, between Down syndrome patients with and without cardiac anomalies. Transthoracic echocardiographic examinations and eNOS single-nucleotide polymorphisms were investigated on seventy-five patients, prospectively. The frequencies of mutant alleles in the eNOS promoter (the -786T/C polymorphism) and exon 7 mutant alleles (the 894G--->T polymorphism) were significantly higher in Down syndrome patients with and without cardiac anomalies. The frequency of the intron GIOT polymorphism did not significantly differ between patients with and without cardiac anomalies. We found a significant relationship between eNOS gene polymorphisms and the congenital heart defects in patients with Down syndrome. Screening for the presence or absence of eNOS polymorphisms may be useful to obtain preliminary data on the risk of congenital heart defects in patients with Down syndrome.

Correlation of astrocyte elevated gene-1, basic-fibroblast growth factor, beta-catenin, Ki-67, tumor necrosis factor-alfa with prognostic parameters in ductal carcinomas and ductal intraepithelial neoplasms

BACKGROUND

Breast cancer is the second most frequent cancer in the world. Although it is widely accepted that the etiology of breast cancer includes both genetic and environmental factors, the molecular mechanism of its development and progression remains poorly understood, and thus far, no specific signature of breast cancer gene expression has been reported to allow for patient-tailored therapy strategies. Hence, it is of great clinical value to further understand the molecular mechanisms underlying the progression of breast cancer and to identify effective early markers for the diagnosis and prognosis of the disease as well as novel therapeutic targets.

MATERIALS AND METHODS

This study was conducted on a total of 90 paraffin-embedded breast tumor samples. Immunohistochemical stains for astrocyte elevated gene-1 (AEG-1), basic-fibroblast growth factor (b-FGF), beta-catenin, Ki-67, tumor necrosis factor-α (TNF-α) were performed on tissue microarray using standard procedures. Each patient age, grade, estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER-2) status, size, lymphovascular invasion, metastasis of lymph node (LNM), nipple and ductal hyperplasia areas were assessed.

RESULTS

We observed significant relationship between the age and LNM or FGF (P = 0.018, 0.035, respectively). The relationship between histological and nuclear grade, LNM, ER, PR, HER-2 and prognostic parameters was evaluated in cases of ductal carcinomas (DC). There was a significant positive correlation between TNF-α, size, LNM (P ≤ 0.0001, 0.002, 0.005). We found that significant relationship between AEG-1 and TNF-α. There was a significant positive correlation between FGF and Ki-67 and negative correlation AEG-1. Although, FGF, TNF-α, AEG-1 staining in DC were observed higher than ductal intraepithelial neoplasms, this observation could not statistically (P ≥ 0.05).

CONCLUSIONS

The present work aims to investigate the relationship between the expression of AEG-1, b-FGF, beta-catenin, Ki-67, TNF-α other prognostic parameters in DC and ductal intraepithelial neoplasm. We found a relationship between these factors.

Argyrophilic nucleolar organizing region associated protein synthesis for cytologic discrimination of follicular thyroid lesions

Fine needle aspiration biopsy (FNAB) of the thyroid gland is an important tool for preoperative diagnosis; however, its benefit is limited for follicular lesions. Nucleolar organizer regions (NORs) are ribosomal gene regions that stain with silver (Ag) when they are active. These regions can be used to differentiate neoplastic and non-neoplastic lesions. We used a new AgNOR technique to investigate FNAB of cases diagnosed as follicular adenoma and carcinoma. Fourteen cases of follicular thyroid carcinoma (FTC) and 28 cases of thyroid follicular adenomas (FA) were stained using the silver NOR-associated protein (AgNOR) technique. One hundred nuclei per sample were examined, AgNORs were counted, and the total AgNOR area/nuclear area (TNORa/Na) ratio of each cell was calculated. We found that cases with FTC had significantly higher TNORa/Na than cases of FA. Also, cases with FTC had significantly higher AgNOR counts than cases with FA. AgNOR counting may help discriminate FTC and FA by routine cytopathology before surgery.

Oral vitamin B12 treatment is effective for children with nutritional vitamin B12 deficiency

AIM

Despite being one of common preventable deficiency disorders, vitamin B12 (vit-B12) deficiency can lead to serious health problems both in children and adult. The familiar treatment through parenteral route for vit-B12 deficiency frequently leads to poor adherence, and adequate response to treatment has lead to interest in oral supplementation. This study investigates the efficacy of oral vit-B12 treatment in children with nutritional vit-B12 deficiency.

METHODS

Forty-seven children (from 1 month to 17 years) with vit-B12 levels below 200 pg/mL were allocated either of two study groups: Group 1 (1-20 months) and Group 2 (6-17 years) which were subdivided according to the duration of treatment (Group 1A&2A: 4 months; Group 1B&2B: 8 months of 1000 μg oral vit-B12, every day for a week, every other day for 2 weeks, 2 days a week for 2 weeks, then once a week).

RESULTS

Vit-B12 levels among all groups were significantly restored following high oral vit-B12 doses (P = 0.013, P = 0.001), the regimen being more effective in Group1A and Group1B. Correlation analysis of serum vit-B12 levels and age at the end of treatment revealed a decreasing trend with the increasing patient age (corelation respectively -65.2%, P = 0.08; -35.4%; P = 0.25).

CONCLUSION

Data from this study indicate that oral vit-B12 (1000 μg) for 4 months is effective, giving clinicians more choice, for treatment of children with nutritional vit-B12 deficiency. However, despite this high dose, lower levels were achieved in older children indicating the necessity of dosage adjustment in accordance with body weight.

The effect of maxillary sinus surgery on its development

CONCLUSION

The study showed that surgery in the maxillary sinus can affect its development.

OBJECTIVE

To quantitatively evaluate the long-term impact of sinus surgery on its development in the rabbit.

MATERIALS AND METHODS

This was an experimental study performed at an academic tertiary medical center using 20 4-week-old New Zealand white rabbits. The rabbits underwent unilateral right maxillary sinus surgery. The contralateral maxillary sinus used as a control did not undergo the operation. The maxillary sinus ostium was enlarged on the operated side. Volumetric analysis of the maxillary sinus was performed 1 year post-surgery. The maxillary sinus volumes of both sides were calculated using Multidedector CT and the volumetric measurements of the operated side were compared with the non-operated side.

RESULTS

Maxillary sinus development was significantly reduced on the surgical side. Maxillary sinus growth on the surgical side was determined as 87% compared with the non-surgical side.

Effects of adenoidectomy in children with symptoms of adenoidal hypertrophy

The purpose of this study was to compare the preoperative symptoms of children who had adenoid hypertrophy with postadenoidectomy symptoms. Sixty children undergoing adenoidectomy were included in this prospective uncontrolled study at the Farabi Hospital of Karadeniz Technical University, an academic tertiary medical center. The symptoms of each child were described by their parents. Adenoidectomy with myringotomy alone or with tympanostomy tube placement was performed in all children. Two months after the operation, the children were re-evaluated for remaining or residual symptoms. Nasal obstruction, mouth breathing, snoring, hearing loss and nasal discharge were present preoperatively in 55 (91.6%), 51 (85%), 50 (83%), 28 (46%) and 45 (75%), respectively. We found that 53 of 60 children (88.3%) completely recovered from their preoperative symptoms. Of the remaining seven patients, four had persistent nasal obstruction, five mouth breathing, three snoring and two hearing loss. We also noted that the parents of 53 of 60 children were satisfied after the operation. Adenoidectomy provided significant relief and improvement of preoperative presenting symptoms, and it also showed a high rate of parent satisfaction.

Kala-azar associated with coombs-positive autoimmune hemolytic anemia in the patients coming from the endemic area of this disease and successful treatment of these patients with liposomal amphotericin B

Kala-azar is an intracellular parasitic infection that infects and multiplies in the macrophages of the liver, the spleen, and the bone marrow. It is characterized by intermittent fever, hepatosplenomegaly, pancytopenia, and hypergammaglobulinemia. Although anemia is a usual finding, Coombs-positive autoimmune hemolytic anemia (AIHA) has rarely been reported with this disease. Pentavalent antimonial compounds remain the mainstay of treatment worldwide. Liposomal amphotericin B (L-AmB) is currently preferred in the treatment of kala-azar because of the resistance to pentavalent antimonals. The authors diagnosed kala-azar associated with Coombs-positive AIHA in 3 patients and treated them with L-AmB (1-5 mg/kg/day) for 30-36 days. Now, all of these patients are healthy following up at the outpatient base for 18-34 months. Kala-azar must be considered in patients with Coombs-positive AIHA and living in and coming from the endemic region for this disease, and it can be successfully treated with L-AmB.

A study on the morphological structure of syrinx in ostriches (Struthio camelus)

The aim of this study was to investigate the topographical, anatomical and histological characteristics of syrinx in five ostriches. It was observed that the syrinx in the ostrich was tracheobronchial type and was composed of three different cartilage groups, namely tympanum, cartilagines (cartt.) tracheosyringeales and cartt. bronchosyringeales. Tympanum and cartt. tracheosyringeales were formed from three and four cartilage rings, respectively, while cartt. bronchosyringeales was formed from three C-shaped cartilage rings. The pessulus did not contain any ossified or cartilaginous tissues and was made up of a double folded mucous membrane extending dorsoventrally from median walls of bronchus primarius into the cavum syringis.