Plasmablastic Lymphoma in a Human Immunodeficiency Virus-positive Child With a Suspicion of Concomitant Primary Immunodeficiency Disorder

Plasmablastic lymphoma (PBL) occurs in the setting of immunodeficiency, in association with human immunodeficiency virus (HIV) infection, in elderly patients, and in the posttransplantation state. It is exceptionally rare in children. PBL is an aggressive lymphoma with a poor prognosis. We present a case of pediatric PBL in an HIV-positive child with suspicion of a concomitant underlying immune deficiency state other than HIV. A 7-year-old girl presented to the pediatric emergency department with complaints of fever and painful swelling on the left side of her face for 15 days, associated with headache, snoring, and difficulty in breathing. She had a history of watery diarrhea, oral thrush, recurrent fever, and hospitalizations for skin infections since the age of 1 year. Histopathological findings were consistent with PBL. Her HIV RNA polymerase chain reaction was positive. She was offered chemotherapy based on the FAB/LMB 96 protocol. This case demonstrates an aggressive presentation of a rare entity, HIV-associated PBL, in a child, with underlying immunodeficiency and highlights the issues which caused a significant challenge in making the diagnosis. The presence of HIV infection and contradicting other immunologic investigations posed a dilemma in establishing an association of PBL in this child. The outcome of patients with this tumor is associated with high mortality.

An Outcome Analysis of Childhood Acute Promyelocytic Leukemia Treated with Atra and Arsenic Trioxide, and Limited Dose Anthracycline

The overall survival of Acute Promyelocytic Leukemia (APL), reported in recent studies, is approaching to 90% wherein, arsenic trioxide (ATO) and all-trans retinoic acid (ATRA) are used as the mainstay of treatment with either limited or no use of anthracycline and cytarabine. This study is aimed to ascertain the outcome of children with APL using similar approach. A total of 30 patients with APL, registered from January 2015 to December 2018, were reviewed. Diagnosis was established on bone marrow aspirate and confirmed by the presence of PML-RARA translocation. Treatment protocol was based on Australian APML 4 study performed by Australian Leukemia Lymphoma Group (ALLG). Lumbar puncture was not performed as it was not part of the protocol due to the risk of bleeding. The mean age in current cohort was 9 years with 53% males. Seven (23.3%) patients died and three (10%) abandoned treatment during induction. Twenty patients completed the intensive phase of chemotherapy and all (100%) of them attained molecular remission (MR). One patient dropped out after MR whereas, 19 remain on follow up with no evidence of disease, reflecting disease free survival (DFS) of 95%. With a median follow up of 2.5 years (range 2.1-4.8 years) the 5 years Kaplan-Meier estimate of OS was 63% and 73%, with and without abandonment, respectively. Analysis of outcome according to risk groups revealed inferior outcome of high risk (HR) group (38% and 50% with and without abandonment, respectively) in contrast to standard risk (SR) group which showed better outcome (82% and 88% with and without abandonment, respectively). The attainment of 100% molecular remission and absence of relapse supports the effectiveness of this regimen. Moreover, it is found to be less toxic and therefore, can be conveniently managed in day-care settings.

Hypercalcemia and Disseminated Osteolytic Lesions With Normal Blood Counts and Absence of Circulating Blasts: A Rare Presentation of Childhood B-Lymphoblastic Leukemia

Hypercalcemia and disseminated osteolytic bone lesions are a rare presentation of pediatric acute lymphoblastic leukemia (ALL). The authors report a 3-year-old boy who presented with hypercalcemia and diffuse osteolytic lesions involving axial and appendicular bones. He had normal complete blood count and the absence of blasts in peripheral smear; however, bone marrow aspirate and trephine were consistent with B-cell ALL. A review of the literature highlights the variable clinical outcome of this rare presentation depending on the presence of hypercalcemia and osteolytic lesions with or without chromosomal translocation t(17;19) and coagulation abnormalities. The patient had no coagulopathy and normal karyotype, and showed excellent response to initial treatment in terms of complete remission and negative minimal residual disease after standard-risk induction chemotherapy. Hypercalcemia with diffuse osteolytic lesions warrants bone marrow examination to rule out leukemia even in the absence of any abnormality in complete blood count. The case was reported for awareness of this rare presentation of ALL so that delays can be avoided for this potentially curable but life-threatening disease.

Effects of hypoxia and isoflurane on liver blood flow: the role of adenosine

We investigated the role of endogenous adenosine in mediating the effects of hypoxia and isoflurane on portal tributary blood flow (PTBF) and hepatic arterial blood flow (HABF) in rats. Liver blood flows were determined using radiolabelled microspheres. Hypoxia resulting from the exposure of rats to an atmosphere containing 15% oxygen for 30 min decreased PTBF (23%) (P<0.05) and cardiac index (15%) (P<0.05), and increased HABF (78%) (P<0.05). Isoflurane (1.4 vol%) increased HABF in both normoxic and hypoxic conditions but did not affect PTBF. The adenosine receptor antagonist 8-phenyltheophylline attenuated the hypoxia-induced increase in HABF but did not affect that resulting from the administration of isoflurane. In conclusion, in contrast to the increase in HABF induced by hypoxia, that induced by isoflurane appears to be independent of endogenous adenosine.

Neuroprotective effects of acetylsalicylic acid in an animal model of focal brain ischemia

Recent studies have shown neuroprotective effects of acetylsalicylic acid (ASA) in cell cultures and hippocampal slices. The present study demonstrates similar effects in a whole-animal modal of focal ischemic stroke. Focal cortical ischemia was produced in Wistar rats by ligation of the common carotid and middle cerebral arteries. Subjects were sacrificed 8 days after ligation, and infarct volume was assessed via automated densitometry. Significant reductions in infarct volume were seen with i.p. ASA doses of 15 mg/kg and above. Reductions occurred when ASA was injected 2 h or 30 min before ligation, but not when it was injected 8 or 24 h before, or 30 min after ligation.

Effect of propofol infusion on splanchnic hemodynamics and liver oxygen consumption in the rat. A dose-response study

BACKGROUND

Propofol has been used for the maintenance of anesthesia. The effects of propofol infusion on splanchnic hemodynamics and liver oxygen consumption, however, have not been reported. In the current investigation, the authors studied the effects of a continuous infusion of propofol on systemic and splanchnic hemodynamics using a new method to measure liver oxygen consumption in awake control and anesthetized rats.

METHODS

Cannulas were inserted into the left ventricle, femoral artery, portal vein, and hepatic vein during ether anesthesia, and the rats were allowed to awaken and recover for 3-4 h before study. Animals were infused for 30 min with either saline (controls) or propofol at a rate of 300, 600, 900, or 1,200 micrograms.kg-1 x min-1. Cardiac output and organ blood flows were measured using radiolabelled microspheres, and blood samples from the femoral artery, portal vein, and hepatic vein were used to determine liver oxygen consumption.

RESULTS

Mean arterial pressure decreased in a dose-dependent manner with a 25% reduction at the highest infusion rate. Systemic vascular resistance similarly decreased, whereas cardiac output remained unchanged at all the infusion rates. Hepatic arterial blood flow increased in a dose-dependent fashion over the dose range studied, to a maximum increase of 120%. Portal tributary blood flow increased by 30% at the highest infusion rate. Total liver blood flow increased in a dose-dependent manner to a maximum of 38%. Total oxygen delivery to the liver by the hepatic artery and portal vein increased in a dose-dependent fashion. Liver oxygen consumption increased in a dose-dependent fashion to a maximum increase of 51% at an infusion rate of 1,200 micrograms.kg-1 x min-1. The percent of oxygen extracted by the liver was not altered by propofol infusion, and hepatic venous oxygen saturation did not decrease at any dose studied. Coronary and renal blood flows were not altered. Arterial PaCO2, increased from 31 +/- 2 mmHg in awake control rats to 41 +/- 2 mmHg in spontaneously breathing rats infused with 1,200 micrograms.kg-1 x min-1 propofol.

CONCLUSIONS

The maintenance of anesthesia using an infusion of propofol resulted in an increase in liver oxygen consumption that was fully compensated for by an increase in oxygen delivery to the liver. Splanchnic hemodynamics and liver oxygenation are not adversely affected during maintenance of anesthesia with propofol in the normal rat.