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.

Coexistence of Kasabach-Merritt Syndrome and placental chorioangioma in a premature infant

Kasabach-Merritt syndrome is a rare life-threatening clinical presentation in neonatal period. it is characterized by giant hemangioma and serious thrombocytopenia. The diagnostic criteria include: 1) hemangiomas on skin, 2) thrombocytopenia or coagulopathy, 3) hemangioma on internal organs diagnosed by ultrasonography, computed tomography or magnetic resonance imaging, and 4) excluding reasons, such as idiopathic thrombocytopenic purpura or hypersplenism.Placental chorioangiomas are the most widespread non-trophoblastic benign tumor-like lesions of placenta. The clinical signs are associated with tumor size. Chorioangiomas larger than 4-5 cm may lead to various maternal and fetal complications.Here, a female premature infant was diagnosed with placental chorioangioma and liver hemangioma during antenatal period. She developed heart failure secondary to non-immune hydrops fetalis in the neonatal period. The atypical giant hemangioma and coagulopathy suggested the diagnosis of Kasabach-Merritt syndrome. The macroscopic and histopathological examination of the placenta confirmed the diagnosis of chorioangioma. The patient died due to purpura fulminans despite the treatment with prednisolone and propranolol that was started on the second day of life. We are presenting this rare case where placental chorioangioma leading to non-immune hydrops fetalis co-existed with Kasabach-Merritt syndrome.

POWER DOPPLER ULTRASOUND MAPPING IN NONOBSTRUCTIVE AZOOSPERMIC PATIENTS PRIOR TO TESTICULAR SPERM EXTRACTION

This study was conducted to localize the testicular regions, which have better blood circulation by power Doppler ultrasonography in patients with nonobstructive azoospermia before testicular sperm extraction (TESE), and to investigate whether these vascularized areas have a high sperm retrieval rate or not. We evaluated 110 testes of 55 cases that were diagnosed as nonobstructive azoospermia. The mean age of the study group was 33 years (range 26 to 42). Patients with Y chromosome microdeletions, karyotype and hormonal abnormalities (except elevated FSH levels) were excluded from the study. In all cases, testes were evaluated by power Doppler ultrasonography before testicular sperm extraction. Testis was divided vertically into five equal parts and the area with maximum vascularity was determined subjectively. During testicular sperm extraction, starting from best-perfused areas, biopsies were done. If no motile or sufficient amount of sperm was found, TESE procedure was tried on the contralateral testis. TESE were performed from 82 testes and for the regions that show good and poor vascularity. The sperm finding rate was 38% and 14%, respectively (OR = 3.55)(p = 0.001). Power Doppler ultrasound mapping of the testis in nonobstructive azoospermic cases is a reliable and informative method to assess spermatogenic foci. It is a noninvasive technique that minimizes the unnecessary removal of hormone producing tissue and gives chance to end the TESE earlier than currently practiced procedures.

Temporary vascular access via the external iliac vein as a salvage procedure: a report of two cases

Central venous catheters (CVCs) provide easy, immediate and rapid vascular access (VA) for hemodialysis (HD) in patients with acute renal failure (ARF), and in an increasing number of patients with end-stage renal disease (ESRD) as well. For this purpose, the vessels mainly used are the cephalic, jugular, subclavian and femoral veins. In some patients, vascular catheter insertion via these routes can become impossible. We report two hopeless cases, in which the external iliac veins (EIVs) were used as a temporary VA insertion site as a last resort.