Risk of abuse of diphenhydramine in children and adolescents with chronic illnesses

Diphenhydramine is generally considered an innocuous drug with a minimal risk for abuse and untoward side effects. We describe children and adolescents with chronic hematologic and oncologic diseases who exhibited drug-seeking behavior or anticholinergic symptoms with the use of diphenhydramine. These cases illustrate that the assumption that this drugs is without significant adverse effects may be unwarranted, especially for children and adolescents with chronic diseases.

Successful therapy of refractory graft versus host disease with tacrolimus and Psoralen plus ultraviolet light

The authors report a patient who developed severe graft versus host disease (GVHD) after undergoing a matched, unrelated bone marrow transplant. Her symptoms worsened despite treatment with cyclosporine, high doses of methylprednisolone, and antithymocyte globulin. After treatment with tacrolimus (FK506) and Psoralen plus ultraviolet light (PUVA), there was complete resolution of all clinical and laboratory evidence of GVHD. This combination may be beneficial to other patients who develop severe GVHD that is resistant to conventional therapy.

Phase I/II study of idarubicin given with continuous infusion fludarabine followed by continuous infusion cytarabine in children with acute leukemia: a report from the Children's Cancer Group

PURPOSE

The Children's Cancer Group (CCG) undertook a phase I study (CCG-0922) to determine a tolerable dose of idarubicin given with fludarabine and cytarabine in children with relapsed or refractory leukemia. The phase I study was extended to a limited phase II study to assess the activity of this combination in children with acute myelogenous leukemia (AML).

PATIENTS AND METHODS

This was a multiinstitutional study within the CCG. Eleven patients were entered onto the phase I study: seven with AML, three with acute lymphoblastic leukemia (ALL), and one with chronic myelogenous leukemia (CML). The maximal-tolerated dose (MTD) of fludarabine and cytarabine determined in a previous study was a fludarabine loading dose (LD) of 10.5 mg/m2 followed by a continuous infusion (CI) of 30.5 mg/m2/24 hours for 48 hours, followed by cytarabine LD 390 mg/m2, then CI 101 mg/m2/h for 72 hours. Idarubicin was given at three dose levels: 6, 9, and 12 mg/m2 intravenously (I.V.) on days 0, 1, and 2. The phase II portion of the trial included 10 additional patients with relapsed or refractory AML.

RESULTS

A dose of idarubicin 12 mg/m2/d for 3 days given in combination with fludarabine and cytarabine was tolerated. The major toxicity encountered was hematologic. Nonhematologic toxicities included transaminase elevations, hyperbilirubinemia, and infections. Eight of 10 patients with AML in the phase II portion (12 mg/m2 idarubicin) achieved a complete remission (CR).

CONCLUSION

This combination is active in patients with relapsed or refractory AML. The major toxicity encountered is hematologic. This regimen may be useful therapy for AML and should be compared with standard induction therapy in children with newly diagnosed AML.

The human homologue of rat NG2, a chondroitin sulfate proteoglycan, is not expressed on the cell surface of normal hematopoietic cells but is expressed by acute myeloid leukemia blasts from poor-prognosis patients with abnormalities of chromosome band 11q23

In our efforts to produce monoclonal antibodies that recognize cell-surface antigens expressed by hematopoietic precursor and stromal cells, we generated a monoclonal antibody, 7.1, which recognizes a 220- to 240-kD cell-surface protein whose N-terminal amino acid sequence is identical to the rat NG2 chondroitin sulfate proteoglycan molecule. This chondroitin sulfate proteoglycan, previously reported to be expressed by human melanoma cells, was not found to be expressed by normal hematopoietic cells, nor was it expressed on the cell surface of cell lines of hematopoietic origin including cell lines with 11q23 abnormalities. It was found on the cell surface of acute myeloid leukemia (AML) blasts and cell lines derived from nonhematopoietic tissues. Samples of leukemic marrow from 166 children with AML enrolled on Childrens Cancer Group protocol 213 were evaluated for cell-surface expression of this proteoglycan molecule. In 18 of 166 (11%) patient samples, greater than 25% of leukemic blasts expressed the NG2 molecule. These 18 patients had a poorer outcome with respect to survival (P = .002) and event-free survival (P = .035) with an actuarial survival at 4 years of 16.7%. Blast cell expression of the NG2 molecule was strongly associated with French-American-British M5 morphology (P < .0001) and abnormalities in chromosome band 11q23, site of the MLL gene. These results show that the NG2 molecule is expressed by malignant hematopoietic cells that have abnormalities in chromosome band 11q23, suggesting that antibody 7.1 may be useful in the rapid identification of this group of poor-prognosis patients.

Invasive Aspergillus sinusitis in pediatric bone marrow transplant patients. Evaluation and management

OBJECTIVES

To evaluate the following: the incidence of invasive Aspergillus sinusitis (AS); the value of surveillance nasal cultures and screening radiologic studies in predicting AS; the clinical criteria used to decide on surgical biopsy in patients suspected of having AS; the surgical and medical management of AS; and the outcome of AS in the peritransplantation period of children who underwent bone marrow transplantation.

DESIGN

Retrospective medical chart review.

SETTING

Tertiary care children's hospital.

PATIENTS

Eighty pediatric patients who underwent bone marrow transplantation for a variety of refractory malignant neoplasms or lymphohematopoietic disorders at the Children's National Medical Center, Washington, DC, from April 1, 1988, to September 30, 1993.

INTERVENTION

Diagnostic surgical biopsies, surgical débridement, and treatment with amphotericin B.

MAIN OUTCOME MEASURE

Resolution of AS and discharge from the hospital.

RESULTS

Seventy-two patients had screening sinus radiographs, 27 of which showed abnormalities. Aspergillus sinusitis developed in three of the patients with abnormal screening radiographs. Fifty-eight patients had screening nasal cultures. One culture was positive for Aspergillus, and histopathologically proved AS developed in this patient. Twelve diagnostic biopsies were done in nine patients. Three biopsy specimens showed histopathologic evidence of AS. The three patients with AS were successfully treated with aggressive surgical and medical therapy and were discharged from the hospital.

CONCLUSION

The incidence of AS was 4% (3/80) in the patients who underwent bone marrow transplantation. Screening radiographs, while not a good predictor of AS, have a role in evaluation of patients undergoing bone marrow transplantation to define preexisting sinus disease. Screening nasal cultures do not reliably predict AS. When AS is suspected and diagnostic biopsy is considered, the seven clinical criteria outlined in this article should be used. Survival of immunocompromised patients with AS requires early diagnosis and aggressive surgical and medical therapy.

Encephalopathy with parkinsonian features in children following bone marrow transplantations and high-dose amphotericin B

Encephalopathy, leukoencephalopathy, and secondary parkinsonism occurred in 3 children with refractory leukemia undergoing allogenic bone marrow transplantation (BMT) who were treated with high-dose amphotericin B for pulmonary aspergillosis or sinus aspergillosis that did not involve the nervous system. Treatment included high-dose cytosine arabinoside, cyclophosphamide, and total body irradiation prior to the BMT. The children developed a progressively worsening encephalopathy and parkinsonian features, characterized by resting tremor, cogwheel rigidity, and masklike facies. Neuroimaging studies showed cerebellar, cerebral, and basal ganglia atrophy, as well as frontal and temporal lobe white matter involvement. Two of the 3 patients recovered, although 1 has residual intellectual impairment. The third succumbed to non-central nervous system Epstein-Barr virus-lymphoproliferative disease and had autopsy-confirmed leukoenephalopathy.

Phase I study of tumor necrosis factor-alpha and actinomycin D in pediatric patients with cancer: a Children's Cancer Group study

In preclinical studies, synergy was observed between tumor necrosis factor-alpha (TNF-alpha) and agents that interact with DNA topoisomerase II, such as actinomycin D (Act D). Based upon this, a Phase I study was conducted in pediatric patients utilizing an escalating dose of recombinant TNF (rTNF) in combination with a fixed dose of Act D. Act D (15 micrograms/kg/day) was administered daily by intravenous push immediately followed by intravenous rTNF daily for 5 consecutive days. Thirty-three patients with refractory malignancies were entered in the study, of whom 28 patients could be evaluated for toxicity. Malignancies included sarcomas (16), Wilms' tumor (6), leukemias (3), and others (3). The starting dose for rTNF was 40 micrograms/m2/day x 5 and was escalated in subsequent patient groups until nonhematopoietic, dose-limiting toxicity occurred. At 240 micrograms/m2/day of rTNF, three of six patients experienced grade 4 toxicity consisting of hypotension, hemorrhagic gastritis, and renal and liver biochemical abnormalities. Evidence of antitumor response was observed in two patients: one with metastatic Ewing's sarcoma and one with Wilms' tumor. We conclude that the maximum tolerated dose of rTNF when combined with Act D is between 200 and 220 micrograms/m2/day x 5 for pediatric patients.

Relapse of acute lymphoblastic leukemia in the inferior rectus muscle of the eye

BACKGROUND

Extramedullary involvement of acute lymphoblastic leukemia (ALL) in sites outside the central nervous system (CNS) or testes is rare and may signal a refractory form of leukemia.

METHODS

The authors describe a child with ALL who experienced a relapse involving the inferior rectus muscle of the eye. This patient had been treated with a bone marrow transplant for previous bone marrow and ovarian relapse.

RESULTS

The patients had a pre-B ALL with a t(1;19) chromosomal translocation and previously had experienced relapse during therapy. At the time of the muscle relapse, she had pancreatomegaly consistent with leukemic infiltration but no CNS or bone marrow disease.

CONCLUSIONS

Relapse of ALL in unusual sites may indicate disease that is particularly difficult to eradicate. Factors in addition to age and leukocyte count at diagnosis determined risk. Additional research is needed to define these factors and develop more effective therapy.

Extended-cycle elutriation to adjust T-cell content in HLA-disparate bone marrow transplantation

We report the development of a double-cycle elutriation (DCE) technique separating 3 or greater logs of T cells from a stem-cell-enriched marrow fraction and the results of phase I T-cell depletion studies with HLA-disparate related bone marrow transplantation (BMT) donors in two patient groups. In group 1, 10 patients with refractory hematopoietic malignancies received combination chemotherapy, total body irradiation (TBI), and immunosuppression (pre- and post-BMT), and hematopoietic rescue with a marrow transplant, depleted of T cells by elutriation. Potentially to promote engraftment and a graft-versus-leukemia (GVL) effect, 0.5 to 0.75 x 10(5) T cells/kg were added back. All 10 patients engrafted. Five patients developed acute graft-versus-host disease (GVHD; four grade II, one grade III) and two subsequently developed chronic GVHD. Two patients have relapsed (median follow-up, 206 days; range, 46 to 1,035). Four patients died of BMT-related complications (three of infection, one of veno-occlusive disease [VOD]). Four patient are disease-free survivors (median follow-up, 960 days; range, 670 to 1,035). Group 2 included five infants, four with congenital lymphohematopoietic deficiencies and one with refractory acute lymphocytic leukemia (ALL). In these infants, busulfan and increased cyclophosphamide were substituted for TBI. Only the ALL patient received added T cells. Three patients engrafted: one has stable mixed chimerism, one relapsed with ALL, and one rejected the marrow. One patient had primary autologous recovery, while another failed to engraft. None developed GVHD. We conclude that, in this setting of HLA-disparate BMT with post-BMT antithymocyte globulin (ATG) and corticosteroids, DCE significantly depletes T cells from the marrow and that a defined number of T cells can be added without the occurrence of severe GVHD.

Expression of lymphoid-associated cell surface antigens by childhood acute myeloid leukemia cells lacks prognostic significance

The prognostic significance of cell surface antigens associated with lymphoid and myeloid lineage differentiation on the blasts of children with acute myeloid leukemia (AML) was evaluated. Leukemic blasts from 176 patients enrolled on Childrens Cancer Study Group Protocol 213 determined to have AML by standard morphologic and cytochemical criteria were immunophenotyped. Cell surface antigens associated with myeloid differentiation were found on blasts from 88.1% of patients (CD15, 44%; CD33, 65%; CD36, 53%; glycoprotein Ib, 9.3%). However, blasts from 30.7% of patients expressed surface antigens thought to be specific for lymphoid lineage differentiation (CD2, 9.4%; CD5, 2.7%; CD19, 34.5%; CD20, 0.8%). In addition, CD34, a glycoprotein found on immature cells of both myeloid and lymphoid lineages, was expressed on the blast cells of 48.2% of patients. With the exception of the lymphoid lineage nonspecific antigen CD4, no correlation was found between white blood cell count at diagnosis, age, and French-American-British morphology, and the expression of any of the lymphoid- or myeloid-associated cell surface antigens studied. Nor was the expression of these antigens prognostically significant with respect to response to induction therapy, death during induction, survival, event-free survival, or survival/event-free survival following remission induction. Multivariate analysis showed that CD4 expression was not an independent predictor of outcome. Thus, this prospective study suggests that expression of lymphoid-associated cell surface antigens as well as myeloid-associated antigens by childhood AML blasts lacks prognostic significance.

Expression of myeloid differentiation antigens in acute nonlymphocytic leukemia: increased concentration of CD33 antigen predicts poor outcome--a report from the Childrens Cancer Study Group

Ninety-eight cryopreserved specimens of acute nonlymphocytic leukemia (ANLL) cells obtained at initial diagnosis of children enrolled on the Childrens Cancer Study Group 251 protocol (CCG 251) were examined by indirect immunofluorescence using four monoclonal antibodies to myeloid differentiation antigens. The relationship between the level of differentiation of ANLL cells as determined by their antigen phenotype and the clinical outcome of treatment, including complete remission (CR) rate, survival, and event-free survival, was evaluated. Most leukemic specimens were determined to express the CD33 antigen (L4F3), a 67-kD protein. Because the level of differentiation of normal myeloid cells is reflected by the concentration of the CD33 antigen expressed, samples were categorized as CD33-bright (immature) versus CD33-dull (mature). Patients with CD33-bright leukemic blasts had a marginally inferior CR rate to those with CD33-dull blasts (P = 0.08). With respect to survival and event-free survival, there was a significantly inferior outcome in the CD33-bright patients (P = 0.04 and P = 0.06, respectively). Reactions of ANLL with anti-CD15 antibody (1G10), anti-CD36 antibody (5F1), or anti-CD17 antibody (T5A7) did not predict clinical outcome. This study indicates that patients whose ANLL blasts displayed the CD33 antigen in an amount associated with immature myeloid cells experienced a worse outcome than patients with ANLL blasts that expressed a phenotype associated with more mature cells.

Immunoglobulin and T cell receptor gene configuration in acute lymphoblastic leukemia of infancy

We examined immunoglobulin (Ig) heavy chain, K light chain, and T cell receptor (TCR) gamma and beta gene configuration in the leukemic cells from a series of infants aged less than 1 year with acute lymphoblastic leukemia (ALL). Each of these 11 cases demonstrated leukemic cell surface antigens that have been correlated with a B cell precursor phenotype. Of the 11, lymphoblasts of 4 retained the germline configuration of both Ig and TCR loci, whereas 7 had rearranged the Ig heavy chain gene. Two of these seven showed light chain gene rearrangement. TCB beta chain rearrangement had occurred in only one of the 11 patients' tumors. No TCR gamma chain rearrangements were identified. These results are in contrast to earlier studies of B cell precursor ALL in children in which Ig heavy chain gene rearrangements were evident in every case and approximately 40% showed Ig light chain rearrangement as well. In addition, 45% of cases of B cell precursor ALL of children had rearranged their gamma TCR genes, and 20% had rearranged beta. These data suggest that ALL in infancy represents an earlier stage of B cell development than is found in B cell precursor ALL of children. ALL in the infant age group has been associated with the worst prognosis of all patients with ALL. This study suggests that the disease in infants differs not only clinically, but also at the molecular genetic level, from the disease in children.

Infectious complications of intraventricular reservoirs in cancer patients

Drug administration via an intraventricular reservoir is useful in the treatment of leukemic and carcinomatous meningitis that occurs in patients who have previously received lumbar intrathecal chemotherapy. The intraventricular route, however, is associated with a higher incidence of infectious complications compared with therapy given by the lumbar route. To characterize the infectious complications associated with such reservoirs, we reviewed the 10-year experience of the Pediatric Branch, National Cancer Institute, National Institutes of Health, and Children's Orthopedic Hospital, Seattle, WA, with 61 patients (49 with leukemia, 8 with lymphoma, 4 with solid tumors) who had intraventricular reservoirs placed for administration of chemotherapy. The reservoirs were in place for a median of 36 weeks and were punctured a median of 29.5 times, Infectious complications occurred in 14 of 61 patients (23%) and Propionibacterium acnes was the most common organism recovered from cultures. Twelve patients (19.7%) had 19 episodes of clinically suspected and microbiologically documented meningitis or of positive intraventricular reservoir cerebrospinal fluid cultures without symptoms which were treated successfully. Local cellulitis occurred at the site of intraventricular reservoir placement in 2 patients (3.3%) and removal of the intraventricular reservoir was necessary for successful management. Nine patients had their intraventricular reservoir removed (5 because of associated infection and 4 because of malfunction unassociated with infection).(ABSTRACT TRUNCATED AT 250 WORDS)

Management of infectious complications of intraventricular reservoirs in cancer patients: low incidence and successful treatment without reservoir removal

At the time of analysis, the first 30 patients with Ommaya reservoirs (OR) at the Children's Orthopedic Hospital and Medical Center in Seattle, Washington had had 32 reservoirs for a mean duration of 28 months. In all, the reservoir chambers had been punctured for either diagnostic or therapeutic purposes a total of 1,287 times with a mean of 40 injections per reservoir and 1.4 injections per month. Six reservoir infections were diagnosed in five patients--a rate of one infection for every 153 reservoir-months. Four infections were attributed to reservoir use--a rate of one infection for every 322 reservoir entries, and less than one infection in 900 entries when a standard aseptic protocol for sampling and injection was applied. There was no correlation between infectious complications and the frequency with which reservoirs were injected, but there was evidence that some of the infections resulted from incomplete compliance with recommended technique for skin preparation and reservoir entry. Four infections were treated successfully with intravenous and intra-reservoir antibiotics without reservoir removal. Only one reservoir had to be removed because of persistent infection. Two other reservoirs were removed because of trauma and malfunction. Twenty-seven patients (90%) retained their original reservoir, up to 9.5 years after implantation. Intraventricular chemotherapy via an indwelling subcutaneous reservoir is a preferred method for delivery of intrathecal chemotherapy, with an acceptable infection risk relative to the benefits of patient comfort and therapeutic efficacy.

Acute lymphoblastic leukemia in infants: evidence for B cell origin of disease by use of monoclonal antibody phenotyping

Since the prognosis of infants with acute lymphoblastic leukemia (ALL) is so poor, it has been suggested that these leukemias may not be lymphoid in origin, but may originate from stem cell, myeloid, or megakaryocytic progenitors. Alternately it has been hypothesized that these leukemias originate in lymphoid cells at the earliest stages of B cell development. Another possibility is that these leukemias may be of more than one lineage. Therefore we examined leukemic blasts from 12 infants with ALL using monoclonal antibodies to myeloid and lymphoid differentiation antigens. The majority of specimens expressed HLA/DR and reacted with B4 (CD19) but failed to react with stem cell, myeloid, megakaryocytic, or T cell associated antibodies. These results support the speculation that the majority of these leukemias arise in cells at the earliest stages of B cell commitment, and are not of a myeloid or biphenotypic nature.

Polypeptides on human B lymphocytes associated with cell activation

Two monoclonal antibodies (MoAbs), designated BB-1 and LB-2, react with distinct polypeptides expressed on activated human B cells. The BB-1 MoAb reacted with a 37,000-dalton polypeptide (Bp37) restricted to pre-B and B-cell blasts and B-cell malignancies. The LB-2 MoAb reacted with a 76,000-dalton polypeptide (p76) found on resting B cells but at higher levels on activated B cells and T cells. Buoyant tonsillar lymphoid cells with a germinal center phenotype express higher levels of Bp37 and p76 than do dense B cells of the mantle zone. Furthermore, the expression of Bp37 and p76 on tonsillar B-cell subsets was distinct from other B-cell antigens such as Bp39, Bp95, Bp135, the C3d receptor and surface IgM. Based on biochemical, cross-blocking, and tissue distribution analyses, these antigens appear to be distinct from previously described B cell and B-cell-blast markers.

Expression of normal myeloid-associated antigens by acute leukemia cells

Monoclonal antibodies that react with hematopoietic cells and their precursors in a stage and lineage restricted fashion were used in indirect immunofluorescence assays to examine leukemic cells from 105 pediatric age patients. The differentiative states of blasts from 42 patients with acute nonlymphocytic leukemia (ANLL) were defined by these antibodies. When these were compared to their morphologic and histochemical levels of differentiation as defined by the French-American-British (FAB) classification, no direct relationship was found. The reactivity of these antibodies with leukemic cells from 63 patients with acute lymphocytic leukemiA (ALL) was also investigated, and the usefulness of these antibodies in distinguishing leukemias of myeloid from those of lymphoid origin was demonstrated.

Immunodiagnosis of childhood ALL with monoclonal antibodies to myeloid and lymphoid associated antigens

Sixty-five cryopreserved leukemic samples from children diagnosed and treated as having acute lymphocytic leukemia (ALL) were retrospectively examined for the presence of lymphoid and myeloid associated antigens by indirect immunofluorescence using monoclonal antibodies. Expectedly, the majority of these specimens expressed antigens known to be expressed on lymphoid, and not myeloid malignancies. These included the common acute lymphoblastic leukemia antigen (CALLA), the p32 B-cell associated antigen, and T-cell associated antigens. Leukemic cells from the 8 remaining patients expressed antigens known to be present on both myeloid and lymphoid leukemias. These included HLA/DR, and the antigens identified by BA-1 and BA-2. Cells from 2 of these 8 patients reacted with antibodies that define antigens present on normal and malignant myeloid cells. Both specimens reacted with 1G10, an anti-granulocyte antibody, and one reacted with 5F1 which reacts with monocytes, nucleated red blood cells, megakaryocytes and platelets. One of these patients relapsed while receiving ALL therapy, and the morphology of her leukemic cells became characteristic of acute monocytic leukemia (AMoL). The second patient failed ALL therapy but responded to standard acute nonlymphocytic leukemia (ANLL) therapy, clearing her peripheral blasts. Thus these studies confirm that cell surface phenotyping with monoclonal antibodies can recognize ALL cells that express myeloid rather than lymphoid associated antigens and demonstrate that the malignant cells display a clinical behavior consistent with the diagnosis of ANLL.