Serotype distribution and antimicrobial resistance of adult Streptococcus pneumoniae clinical isolates over the period 2001-2008 in Crete, Greece

BACKGROUND

We report on the serotype distribution and the antimicrobial susceptibility patterns (ASP) to 19 antibiotics of 195 Streptococcus pneumoniae isolates (41 invasive) collected over the period 2001-2008 from adult patients.

MATERIAL AND METHODS

Pneumococcal isolates were serotyped by the Quellung reaction, and ASP testing was performed using E-test.

RESULTS

Isolates with intermediate and high-level resistance to penicillin increased from 17 and 12.4% over the period 2001-2004 to 31.1 and 16.7% over the years 2005-2008, respectively (p = 0.03). Macrolide resistance increased from 27.6 to 38.9%, but this was not significant (p = 0.13), while resistance to trimethoprim-sulfamethoxazole did not change over time, with approximately one fourth of the isolates being resistant. Only one isolate was resistant to fluoroquinolones. Multi-resistance was observed among 42 (58.1%) penicillin non-susceptible strains. The isolates tested belonged to 20 different serotypes. Serotypes 19F and 19A were the most common among penicillin-resistant isolates. The currently licensed 23-valent pneumococcal polysaccharide vaccine covered 98.4% of all 186 typeable S. pneumoniae strains.

CONCLUSION

Our study emphasizes the importance of continued serotyping and surveillance of antimicrobial susceptibility of all S. pneumoniae clinical isolates, especially invasive ones, in order to guide the clinician in the choice of appropriate empirical antibiotic therapy for serious pneumococcal infections.

Erythema nodosum associated with Salmonella enteritidis

BACKGROUND

Erythema nodosum (EN) is the most frequent type of panniculitis in childhood. Although frequently idiopathic, it may be associated with a wide variety of conditions ranging from infections, to sarcoidosis, to collagen vascular diseases to drugs.

CASE REPORT

We present an 8-year-old boy who developed EN during the course of febrile gastroenteritis due to salmonella enteritidis. He received intravenous ampicillin 150 mg/kg/day divided in equal doses every six hours for 10 days. The skin lesions gradually disappeared, and he recovered fully without sequelae.

CONCLUSIONS

Salmonellosis should be considered in the differential diagnosis of EN in children with gastrointestinal symptoms, and stool cultures should be performed when indicated.

Changes in tuberculin sensitivity among first-grade students of elementary schools in Evros, Greece due to immigration

OBJECTIVE

To investigate the tuberculin sensitivity trends among first-grade students of elementary schools tested according to the Greek national school-based screening and vaccination programme.

STUDY DESIGN

Retrospective analysis of tuberculin skin test (TST) results from 1988 to 2004 in unvaccinated first-grade students in Evros, Greece.

METHODS

All 6-7-year-old children who were unvaccinated for tuberculosis were tested by a highly experienced team. This study tested whether gender (male vs female), national origin (native vs foreign-born children) and place of residence (urban vs semi-urban vs rural) correlated with tuberculin reaction positivity.

RESULTS

In total, 8588 children (47.1% girls) were tested. Tuberculin reaction positivity was independent of gender. The difference in TST positivity between native and foreign-born children between 1993 and 2004 was highly significant, with substantially more foreign-born children having a positive Mantoux test (P<0.0001). The percentage of children with a positive TST peaked at 13% in 1995 due to initial admission of foreign-born children, originating from countries of the former Soviet Union, into the Greek educational system. In addition, a positive Mantoux test was more common among children living in rural (8.1%) and semi-urban (6.4%) areas compared with children living in urban areas (3.5%, P<0.0001).

CONCLUSION

The increase in TST positivity noted was due to admission of foreign-born children into the Greek educational system. School-based tuberculosis screening programmes should continue in Greece because the prevalence of tuberculosis appears to show substantial variation between years.

Thrombocytosis in childhood

Thrombocytosis is a frequent finding in hemograms obtained from hospitalized and ambulatory children due to the widespread use of automated blood cell counters. Pediatricians are commonly puzzled in cases of thrombocytosis to determine the underlying cause and the need for therapy. The purpose of this review is to assist the general pediatrician into dealing with this common hematological finding in every day clinical practice. Fortunately, primary thrombocytosis or essential thrombocythemia, a clonal disease, is exceedingly rare in childhood, but may be associated with thromboembolic and hemorrhagic complications. On the other hand, secondary or reactive thrombocytosis is very common and is due to a variety of conditions, such as acute and chronic infections, iron deficiency, bleeding, hemolytic anemias, collagen vascular diseases, malignancies, drugs and splenectomy. Treatment of reactive thrombocytosis should be directed to the underlying problem alone. Administration of platelet aggregation inhibitors such as aspirin is unwarranted. Consultation is necessary only for the rare child with extreme thrombocytosis who has clinical and/or laboratory criteria consistent with essential thrombocythemia, or in whom a hemorrhagic or thrombotic complication has developed.

Infantile fibromatosis of the mandible: a case report

We report an aggressive tumour in a 5-year-old girl causing facial disfigurement. Imaging confirmed a solid, diffusely enhancing mass at the right internal pterygoid muscle, infiltrating the adjacent bone. Surgical excision and reconstruction of the mandible were performed. Histology revealed aggressive infantile fibromatosis. No recurrence was noted 7 months later. Infantile fibromatosis may mimic malignancies and should be considered in aggressive mandibular soft tissue masses, in order to carefully plan biopsy and reconstructive surgery.

Association between bone scintigraphy and serum levels of tumor markers in the detection of bone disease in breast cancer patients

PURPOSE

To evaluate the diagnostic value of bone scan in association with measurements of serum CEA, CA 15-3 and TPA levels in breast cancer (BC) patients.

PATIENTS AND METHODS

From September 1999 to January 2005, 89 women with BC who had undergone bone scintigraphy as part of their follow-up were retrospectively evaluated. Serum tumor markers levels were compared with the results of bone scintigraphy. Patients with positive bone scans were divided into 3 groups: group 1: 1-3, group 2: 4-5, group 3: >5 bone lesions. Serum CEA, CA 15-3 and TPA levels of 7 ng/ml, 35 U/ml and 90 U/I, respectively, were adopted as the upper limit of normal.

RESULTS

Serum CA 15-3 was significantly higher in patients with a positive bone scan (p=0.017). For CEA and TPA, no significant difference was found between patients with and without bone metastases. Twenty-five of 70 patients (36%) with normal CEA had bone metastases. Four of 50 (8%) patients with normal CA 15-3 and 15 of 51 (29%) patients with normal TPA had a positive bone scan. The combination of CA 15-3 with TPA showed 100% sensitivity in detecting bone metastases in all patient subgroups. In all 42 patients without bone metastases, CA 15-3 and/or TPA levels were normal.

CONCLUSION

CA 15-3 but not CEA or TPA is sensitive and specific for the correct determination of bone scintigraphy. CA 15-3 plus TPA represent the best combination in association with bone scanning. However, due to frequent false negative results of all tumor markers, it is not recommended to reject a bone scan on the basis of tumor markers levels.

Morganella morganii infections in a general tertiary hospital

BACKGROUND

Morganella morganii is a commensal Gram-negative bacillus of the intestinal tract of humans and other mammals and reptiles. Few reports exist in the literature regarding infections caused by this organism.

METHODS

A retrospective study at the 650-bed University Hospital of Heraklion, Crete, Greece was performed during a 4-year period (2001-2004) to identify and analyze infections caused by M. morganii.

RESULTS

Twenty-four patients had M. morganii isolated from clinical specimens during the study period. Thirteen patients (54%) suffered from skin and soft tissue infections, five from pyelonephritis, three from female genital tract infections, one from pneumonia, one from gangrenous appendicitis, and one from tonsillitis. M. morganii was a constituent of polymicrobial infections in 14 patients (58%). The patients received various antibiotics, i.e., six patients received ciprofloxacin, four piperacillin/tazobactam, two amoxicillin/clavulanic acid, one ticarcillin/clavulanic acid, one ceftriaxone, one imipenem, and one cefuroxime monotherapy, whereas the remaining eight received antibiotic combinations. Two (both debilitated) of 24 patients (8%) died, despite antibiotic treatment.

CONCLUSION

Skin and soft tissue infection was the commonest type of infection due to M. morganii in our series. M. morganii is commonly a part of polymicrobial infections and can rarely cause fatalities in debilitated patients.

Antimicrobial resistance of Mycobacterium tuberculosis isolates from children in Greece, 1994-2004

OBJECTIVE

To document the prevalence of resistance to various agents of Mycobacterium tuberculosis strains derived from children over 1994-2004.

DESIGN

We prospectively studied the susceptibility patterns of 77 strains of M. tuberculosis isolated from the same number of children, which provided 112 positive samples.

RESULTS

Most children were boys (53.2%), native Greeks (87%) and aged under 2 years (41.5%). Sample origin was mainly gastric fluid (97 cases, 86.6%). Sixty-one isolates (79.2%) were susceptible to all anti-tuberculosis agents and 16 (20.8%) were resistant to > or =1 drug. Multidrug resistance (MDR), resistance to at least isoniazid (INH) and rifampicin (RMP), was seen in three cases (3.9%). On comparing resistance to INH, RMP and streptomycin (SM) and MDR in children and adults diagnosed with tuberculosis in our centre during the same time period, SM resistance was significantly more common in children (P < 0.001), while a trend for increased resistance to INH was also observed in children (P = 0.079).

CONCLUSION

Resistance of M. tuberculosis isolates to the first line anti-tuberculosis drugs appears to be comparable in children and adults in Greece, while SM resistance appears to be more common in children. Tracing the sources of these children is important for the effective surveillance and treatment of tuberculosis.

Comparative effects of ertapenem, imipenem, and meropenem on the colonization of the gastrointestinal tract of mice by Candida albicans

We evaluated the effect of three carbapenems on gut colonization of mice by Candida albicans. A total of 150 Crl:CD1 (ICR) BR mice were fed chow containing C. albicans or regular chow. Both groups were subsequently treated either with one carbapenem or with normal saline for 10 days. Stool cultures to determine colonization by C. albicans were performed immediately before, at the end, and one week after the end of treatment. Candida-colonized mice that received carbapenems had substantially higher C. albicans concentrations than control animals fed C. albicans, especially if they received ertapenem. Mice fed regular chow and treated with the study antibiotics or saline did not have Candida in their stools. Candida was not detected in the internal organs of any group of mice.

Resistance of Mycobacterium tuberculosis isolates in different populations in Greece during 1993-2002

OBJECTIVE

To document the prevalence of resistance of Mycobacterium tuberculosis to isoniazid (INH), rifampicin (RMP) and both combined (multidrug resistance [MDR]) in Greece from 1993 to 2002.

DESIGN

We studied a single sputum sample per patient from 4108 patients referred to the Greek National Referral Centre for Mycobacteria. Patients were divided into native Greeks, immigrants and repatriated Greeks originating from the former Soviet Union. Prior treatment status was not recorded.

RESULTS

A statistically significant increase in resistance to INH and RMP and MDR was noted comparing the years 1993-1997 to 1998-2002 (P < 0.0001). Resistance to INH and RMP and MDR rose from 5.6% to 7.71%, from 1.57% to 4.49% and from 1.23% to 3.98%, respectively, among native Greeks and from 23.63% to 32.91%, from 6.36% to 15.19% and from 6.36% to 13.92% among repatriated Greeks. Smaller changes were seen among immigrants (from 15.43% to 9.57% for INH, from 5.51% to 6.12% for RMP and from 5.71% to 5.32% for MDR).

CONCLUSION

We documented an increase in M. tuberculosis resistance to INH and RMP, and MDR. This was mainly limited to native and repatriated Greeks. Although this is likely the result of immigration and of mismanagement of index cases in Greece, molecular methods are needed to better describe the situation.

Effects of vancomycin, teicoplanin, linezolid, quinupristin-dalfopristin, and telithromycin on murine gut colonization by Candida albicans

Crl:CDI(ICR) BR adult mice were fed chow containing Candida albicans or regular chow. Both groups were subsequently given either antibiotics acting mainly against Gram-positive organisms or normal saline for 10 days. Stool cultures were performed before, at the end, and one week after discontinuation of treatment to determine the effects on the stool yeast concentration. Candida colonized mice treated with vancomycin, teicoplanin, linezolid, quinupristin-dalfopristin or telithromycin had higher colony counts of yeast in their stools than control Candida fed mice treated with saline. This increase was not statistically significant. Mice fed regular chow treated with the study drugs or saline did not have any yeasts in their stools. Dissemination of Candida was not observed in the visceral organs of any mouse.

Serotype distribution and antimicrobial resistance of Salmonella enterica from patients with gastroenteritis in Crete, Greece

The aim of the present study was to determine the serotype distribution and the evolution of antimicrobial resistance among Salmonella enterica strains isolated from patients with diarrhea in Crete, Greece, during a 5-year period (2000-2004). Among the 401 S. enterica isolates recovered, serotype Enteritidis was the most prevalent (66.6%), followed by serotype Typhimurium (14.2%). The rates of resistance to ampicillin, amoxicillin-clavulanic acid, gentamicin, chloramphenicol, tetracycline, nalidixic acid and trimethoprim-sulfamethoxazole were 8.5, 7, 0.7, 5.4, 14.2, 2.7 and 2.7%, respectively. A marked decrease in resistance was observed during the study period. Resistance and multidrug resistance was most common in serotype Typhimurium. The extended-spectrum beta-lactamase production observed in one strain of S. enterica serotype Virchow and the reduced ciprofloxacin susceptibility detected in 2.7% of the isolates studied are causes of concern.

Metastatic uterine leiomyosarcoma coexisting with papillary carcinoma of the thyroid gland

Metastatic leiomyosarcoma to the thyroid gland has rarely been described. We report a 54-year-old postmenopausal woman with uterine leiomyosarcoma, who presented with a single "cold" nodule in the right thyroid lobe 3 months after hysterectomy. The lesion was identified as a papillary thyroid carcinoma. In a separate area of the thyroid, a 1.2-mm area of a malignant mesenchymal neoplasm with morphologic and immunohistochemical features of leiomyosarcoma existed. Seven months after thyroidectomy the patient developed micronodular lung disease visible on successive chest computed tomography scans, consistent with metastatic disease from the primary uterine leiomyosarcoma that showed very good and prolonged response to chemotherapy. The thyroid papillary carcinoma was likely the recipient of an early and possibly the first metastasis of the patient's uterine leiomyosarcoma. This is the first report of metastatic leiomyosarcoma coexisting with a primary thyroid carcinoma and supports the possibility of a common pathway connecting thyroid gland neoplasms and sarcomas.

Antimicrobial resistance of Streptococcus pneumoniae isolates in Athens, Greece

In order to determine the current antibiotic susceptibility of Streptococcus pneumoniae strains in Greece, the present study was performed on 282 clinical isolates collected from patients at the Sotiria Chest Hospital of Athens, Greece, during the years 1997-2003. Susceptibility testing revealed that 52 (18.4%) isolates were not susceptible to penicillin, with 13.1% demonstrating intermediate and 5.3% high-level resistance. One of the penicillin-non-susceptible isolates was also resistant to cefotaxime. Comparison with results of a previous study conducted at the same hospital during the period 1992-1993 showed that penicillin resistance had increased by 4.5%. The results of this study indicate the antimicrobial susceptibility of Streptococcus pneumoniae continues to change in Greece and continuous surveillance remains important for guiding empirical antibiotic therapy.

Veno-occlusive disease of the liver associated with chronic myelomonocytic leukemia treated with vincristine and standard doses of cytarabine

A unique case of a 72-year-old man with chronic myelomonocytic leukemia (CMML) who developed hepatic veno-occlusive disease (VOD) after treatment with a single dose of vincristine and standard doses of cytarabine is described. Unexpected peroneal nerve palsy suggestive of vincristine neurotoxicity occurred concurrently and pointed to vincristine as the most likely cause of the VOD. To the best of our knowledge, association between vincristine and hepatic VOD has not been previously described in chemotherapy-naive patients with CMML.

Bloodstream Infections in Patients with Solid Tumors: Associated Factors, Microbial Spectrum and Outcome

BACKGROUND

Although patients with malignant diseases are at increased risk for bloodstream infections (BSIs), limited data are available for those with solid tumors.

PATIENTS AND METHODS

The etiology, clinical features and outcome of BSIs were retrospectively studied in patients with solid tumors treated at the Department of Medical Oncology at the University Hospital of Heraklion, Greece, from November 1995 through June 2000.

RESULTS

A total of 157 episodes of BSIs was identified among 137 patients over the study period. The majority of the episodes (128; 82%) occurred in non-neutropenic patients. 80 of 157 (51%) of the episodes were healthcare-associated, 35% (55 of 157) were nosocomial and 14% (22 of 157) were community acquired. A single pathogen was isolated in 86% of the episodes. A total of 184 pathogens was isolated (51% gram-negative rods, 44% gram-positive cocci, 3% anaerobes and 3% fungi), while the portal of entry was identified in 104 of 157 (66%) of the episodes. The site of the primary tumor or the metastases were the source of BSI in 39 of 104 (37.5%) of the episodes with an identified source. The overall infectious mortality was 20% and was significantly higher when the initial empirical antibiotic therapy was inappropriate (39%; p < 0.001) and in the presence of shock (63%; p < 0.001).

CONCLUSION

BSIs in patients with solid tumors are frequently healthcare associated and in a large percentage the portal of entry can be identified. Neutropenia is not as common as in patients with hematologic malignancies. Inappropriate initial empirical antibiotic therapy and shock are clinical factors associated with worse outcomes.

A case of Opisthorchis felineus infestation in a pilot from Greece

We describe the case of a 28-year-old man from Greece with Opistorchis felineus infestation. The patient presented with intense abdominal pain, bilious emesis and eosinophilia. He probably acquired the infection overseas, since he was a commercial airline pilot who used to fly to endemic areas and to consume raw or undercooked fish. He was successfully treated with praziquantel administered in divided doses over a single day. Opisthorchiasis is common to eastern Europe and areas of the former Soviet Union, but extremely rare in Greece. Medical personnel should be cognizant of this parasitic infection, since world travel can spread it to areas of the world unaccustomed to it.

Systemic mycoses in the immunocompromised host: an update in antifungal therapy

Despite significant advances in the management of immunosuppressed patients, invasive fungal infections remain an important life-threatening complication. In the last decade several new antifungal agents, including compounds in pre-existing classes (new generation of triazoles, polyenes in lipid formulations) and novel classes of antifungals with a unique mechanism of action (echinocandins), have been introduced in clinical practice. Ongoing and future studies will determine their exact role in the management of different mycoses. The acceleration of antifungal drug discovery offers promise for the management of these difficult to treat opportunistic infections.

Brachyspira (Serpulina) pilosicoli spirochetemia in an immunocompromised patient

The case of an elderly immunocompromised man with non-Hodgkin's lymphoma who presented with fever, abdominal pain and bloody diarrhea is described. Brachyspira pilosicoli was isolated from culture. The patient was treated with penicillin G i.v. and became afebrile. B. pilosicoli is a recently recognized enteric pathogen of humans and animals. Intestinal spirochetosis should be included in the differential diagnosis of any immunocompromised or critically ill patient with dysentery.

Common symptoms--different diseases: coexistence of neurosyphilis and non-Hodgkin's lymphoma

We describe the case of a 32-year-old man with generalized lymphadenopathy who was diagnosed with a low-grade follicular small-cleaved cell lymphoma. The patient developed hearing loss, tinnitus and cerebrospinal fluid (CSF) pleocytosis attributed to central nervous system (CNS) infiltration by his malignancy, while receiving chemotherapy with vincristine, cyclophosphamide and prednisone. Despite intrathecal chemotherapy with methotrexate, the CSF pleocytosis persisted. Neurosyphilis was suspected because of prior history of gonorrhea and was confirmed with serologic studies of blood and CSF and from the decline of the anti-treponemal antibody titers with appropriate antibiotic therapy. Syphilis should be considered in the differential diagnosis of patients with generalized lymphadenopathy and neurologic signs or symptoms.

Merkel cell carcinoma: a case series of twelve patients and review of the literature

BACKGROUND

Merkel cell carcinoma (MCC) is a rare tumor of the skin.

MATERIALS AND METHODS

A retrospective analysis of 12 cases of MCC diagnosed and treated over a 14-year period.

RESULTS

Seven females and 5 males, with a median age of 72 years and MCC of the face (5), trunk (1) and extremities (6), were studied. The stage was I in 2 cases and II in 10. Eight patients had surgery, two surgery and chemotherapy and two chemotherapy only. The last two patients died of disease after 10 and 16 months. Three patients suffered locoregional recurrence after 4, 6 and 24 months and three were lost to follow-up after 8, 9 and 24 months while disease-free. Two disease-free patients died of unrelated causes after 4 and 48 months, while three were alive and well after 24, 48 and 84 months. The three relapsing patients received chemotherapy in addition to local radiation in one case. One is alive and well, the other alive with disease and the third died of disease after 84, 107 and 10 months, respectively.

CONCLUSION

MCC often recurs locally. Surgery is the treatment of choice, while radiotherapy is important for local control. Chemotherapy produces responses in the neoadjuvant setting or after relapse.

Lack of prognostic significance of intratumoral angiogenesis in nonmetastatic osteosarcoma

BACKGROUND

A need exists to stratify patients with nonmetastatic osteosarcoma into risk subcategories to administer risk-adapted therapy. Intratumoral angiogenesis determined at diagnosis may have a prognostic significance in this malignancy.

PATIENTS AND METHODS

The authors performed a retrospective immunohistochemical study on archival pathologic material from patients with nonmetastatic osteosarcoma, excluding patients with purely chondroblastic tumors associated with hypovascularity of the cartilaginous stroma. Representative sections from the diagnostic biopsies were stained with a murine monoclonal antibody directed against CD34, an endothelial cell marker. Two pathologists unaware of the patients' long-term outcome counted microvessels in 10 microscopic fields from the most active areas of neovascularization.

RESULTS

Between March 1988 and December 1996, 15 girls and 14 boys (median age 12.6 y, range 4.3-18.3) were identified. Seven patients had died of metastatic disease at a median of 3.4 years (range 0.8-7.4) after diagnosis; 22 were alive with no evidence of disease at a median follow-up of 6.8 years (range 2.7-11.4). There was no significant difference in the number of microvessels per field (pathologist 1, median 19 vs. 18.5; pathologist 2, median 15 vs. 10) between survivors or patients who died of metastatic disease. The correlation between the measurements of the two pathologists was excellent (correlation coefficient 0.87).

CONCLUSIONS

Intratumoral neovascularization determined at diagnosis does not correlate with long-term outcome in patients with nonmetastatic osteosarcoma. A prospective study is necessary to confirm these results.

Orofacial viral infections in the immunocompromised host

Orofacial viral infections are common in immunocompromised patients. Herpes simplex virus (HSV) infections are the most common. Varicella-Zoster virus (VZV) infections are less common, but usually more severe. Epstein-Barr virus (EBV) may produce ulcers, lymphoproliferative syndromes or oral hairy leukoplakia (HL). Human herpes virus 6 (HHV 6) may be the etiology of recurrent aphthous stomatitis, while human herpes virus 7 (HHV 7) has an unclear role. Human herpes virus 8 (HHV 8) is the etiologic agent of Kaposi sarcoma. Human papilloma viruses (HPVs) cause warts, papillomas and epithelial hyperplasia. Molluscum contagiosum is caused by a poxvirus. All herpes viruses (HSV, VZV, CMV, EBV, HHV 6, HHV 7, HHV 8) and many HPVs are associated with neoplasias. Research is ongoing to clarify the role of other viruses in the development of infections and lesions in the orofacial area.

Fractionated cyclophosphamide and etoposide for children with advanced or refractory solid tumors: a phase II window study

PURPOSE

Cyclophosphamide (CPA) has a broad spectrum of activity against solid tumors. Hepatic self-induction of the active metabolite 4-hydroxycyclophosphamide occurs after repeated administration. We evaluated the clinical efficacy of a window regimen that administers fractionated CPA in conjunction with etoposide (VP16) in children with advanced or refractory solid tumors.

PATIENTS AND METHODS

Seventeen children with advanced (n = 12) or refractory (n = 5) solid tumors were entered onto this phase II window study. The treatment regimen consisted of intravenous (IV) CPA 500 mg/m(2)/d and IV VP16 100 mg/m(2)/d. Both drugs were administered daily by short infusions for 5 consecutive days.

RESULTS

A total of 34 courses were administered, with a median of two courses per patient. The median interval between chemotherapy courses was 21 days (range, 17 to 35 days). Thirty-three courses were assessable for toxicity, and all patients were assessable for response. No life-threatening toxicities were observed. The incidence of grade 3 or 4 neutropenia was 94% and of fever and neutropenia 38%. Fever and neutropenia occurred after 12 of 26 courses without recombinant human granulocyte colony-stimulating factor (rhG-CSF) and after one of eight courses with rhG-CSF (P =. 09). Grade 3 or 4 thrombocytopenia occurred after 10 courses (29%). There were no positive blood cultures. One heavily pretreated patient developed a localized perirectal abscess that required drainage. There were 10 patients (59%) with partial responses, four (23.5%) with stable disease, and three with progressive disease.

CONCLUSION

Fractionated IV CPA and VP16 over 5 days can be safely administered in children with advanced or refractory solid tumors and has notable antineoplastic activity.

Ratio of methotrexate to folate uptake by lymphoblasts in children with B-lineage acute lymphoblastic leukemia: a pilot study

PURPOSE

Methotrexate (MTX) remains one of the most effective drugs for the treatment of children with acute lymphoblastic leukemia (ALL). Because MTX and 5-methyltetrahydrofolate (5CH3THF) share uptake and metabolic pathways, the efficacy of MTX is likely to depend not only on its metabolism but also on how well folate is accumulated by lymphoblasts. The authors' goal was to compare in vitro folate and antifolate uptake in B-lineage lymphoblasts from patients who remained in continuous complete remission (CCR) and those in whom relapse occurred.

PATIENTS AND METHODS

Twenty-four children with B-lineage ALL were studied at diagnosis (n = 20) or relapse (n = 4). Lymphoblasts obtained by bone marrow aspiration were incubated for 24 hours in vitro with 0.05 microM 5CH3[3H]THF or 1 microM [3H]MTX.

RESULTS

As of July 1999, 16 patients studied at diagnosis remained in CCR at a median follow-up of 45 months after achieving remission. Two of the patients studied at relapse are in second CCR; the remaining two died from progressive disease. The median uptake of neither [3H]MTX nor 5CH3[3H]THF differed significantly between the 16 patients in first CCR studied at diagnosis and the 4 patients studied at relapse. However, the median ratio of [3H]MTX:5CH3[3H]THF uptake differed significantly for patients who remained in first CCR versus patients studied at relapse.

CONCLUSIONS

The uptake of [3H]MTX in relation to 5CH3[3H]THF by leukemic lymphoblasts in vitro may correlate positively with treatment outcome in children with B-lineage ALL. A larger study of homogeneously treated patients is necessary to confirm these results.

Elective splenectomy in children with idiopathic thrombocytopenic purpura

PURPOSE

The aim of this study was to review the safety and efficacy of elective splenectomy in children with idiopathic (immune) thrombocytopenic purpura (ITP).

METHODS

The authors reviewed the medical records of children with ITP treated with elective splenectomy at Children's Medical Center of Dallas since 1961. Indication for splenectomy was symptomatic thrombocytopenia unresponsive to medical management.

RESULTS

Thirty-eight evaluable patients who had elective splenectomy for ITP were identified. Twenty-one (55%) were girls and 17 (45%) were boys. Twenty-two had splenectomy since January 1990. Age at diagnosis ranged from 6 months to 15.9 years (median 9 years), and age at splenectomy ranged from 3.6 to 16.4 years (median 11.8). Laparoscopic splenectomy was performed in 11 patients. No patient died and only one (2.6%) had postoperative hemorrhage. There were no other complications related to surgery. No cases of postsplenectomy sepsis were observed. At follow-up ranging from 1 month to 19.9 years (median 2.1 years), 29 patients (76.3%) had a normal platelet count (>150 x 109/L) and 4 (10.5%) had a platelet count between 50 and 150 x 109/L. Only two of the five (13.2%) remaining patients who continued to have a platelet count less than 50 x 109/L had hemorrhagic manifestations necessitating intermittent therapy with corticosteroids.

CONCLUSION

Laparoscopic or open splenectomy is a safe and effective procedure for children with chronic or refractory ITP and should be considered when medical management fails or causes excessive toxicity.

Outpatient penile aspiration and epinephrine irrigation for young patients with sickle cell anemia and prolonged priapism

The optimal management of prolonged priapism for patients with sickle cell anemia (SCA) has not been established. We prospectively studied in an outpatient setting the efficacy and safety of a procedure that employs aspiration of blood from the corpora cavernosa and irrigation with a dilute epinephrine solution under local anesthesia to relieve priapism in young patients with SCA. If hydration and analgesics failed to produce detumescence or if priapism had lasted >4 hours, the protocol was activated in the emergency room or clinic. Fifteen patients with homozygous SCA (Hb SS) were treated on 39 occasions; 10 patients were treated once, 1 patient twice, 2 patients 3 times, 1 patient 6 times, and 1 patient 15 times. Median age of patients at first treatment was 14.3 years (range, 3.9-18.3 years). The procedure was successful in producing immediate detumescence on 37 of 39 occasions (95% efficacy, 95% confidence intervals (CI): 81%-99%). No serious immediate or long-term side effects were observed. None of the patients who demonstrated detumescence required hospitalization. The 2 patients whose priapism persisted after aspiration and irrigation presented with episodes lasting >24 hours. All evaluable patients whose priapism resolved after aspiration and irrigation self-reported normal erectile function at a median of 40 months (range, 3-58 months) after the last procedure. Thus, aspiration of the corpora cavernosa followed by irrigation with dilute epinephrine is effective in producing immediate and sustained detumescence and should be the initial therapy employed for patients with SCA and prolonged priapism. (Blood, 2000; 95:78-82)

Prevalence of priapism in children and adolescents with sickle cell anemia

A questionnaire survey was conducted of patients with homozygous sickle cell anemia (Hb SS) and sickle cell beta(0)-thalassemia (Hb S-beta(0)) between 5 and 20 years of age to determine the prevalence and characteristics (number of episodes, timing, duration, cause, or precipitating event) of priapism. Ninety-eight male patients or their parents were surveyed by the same male investigator using a structured verbal interview, which was modified according to the age of the patient. Ninety-four patients had Hb SS and four Hb S-beta(0) thalassemia. Eleven (11%) patients were known to have experienced priapism previously. In response to the questionnaire, 16 of the remaining 87 (18%) patients reported having had priapism on one or more occasions. The actuarial probability of experiencing priapism by 20 years of age was 89% (+/- 9%). The mean age at the initial episode was 12 years, the mean number of episodes per patient was 15.7 (median, 1; range, 1-100), and the mean duration of an episode was 125 minutes. Episodes typically occurred around 4:00 am, and 75% of the patients surveyed had at least one episode starting during sleep or upon awakening from sleep. The prevalence of priapism in children and adolescents with SCA is much higher than previously described. Since early intervention and treatment may prevent irreversible penile fibrosis and impotence, patients and parents should be educated about this complication in advance of its occurrence.

Transient monosomy 7: a case series in children and review of the literature

BACKGROUND

Monosomy 7 and deletions of the long arm of chromosome 7 [del (7q)] are recurrent, nonrandom chromosomal abnormalities associated with both de novo and therapy-related myelodysplastic syndromes (MDS). The overall prognosis for children and adults with these chromosomal abnormalities is poor. In the current report, the authors present five children with MDS associated with monosomy 7/del(7q) who achieved spontaneous hematologic disease remission as well as a review of the literature.

METHODS

Five children with either de novo or treatment-related MDS who achieved spontaneous hematologic disease remission are presented. Relevant clinical, cytogenetic, and fluorescent in situ hybridization data are included.

RESULTS

All patients were boys. Three had de novo MDS whereas two others previously had received chemotherapy for another malignancy. Four patients achieved spontaneous and durable hematologic disease remission that was associated with cytogenetic disease remission in all three patients tested. The fifth patient developed a disease recurrence and died with evidence of clonal evolution after a long interval of hematologic and cytogenetic remission.

CONCLUSIONS

A subset of children who develop MDS associated with monosomy 7 or del(7q) achieve spontaneous hematologic and cytogenetic improvement. Although this appears to be uncommon, further data are needed to determine the percentage of patients who improve without therapy and to define clinical characteristics that may predict this clinical outcome. These findings suggest that monosomy 7/del(7q) is insufficient to produce full leukemic transformation.

Acute renal failure due to obstruction in Burkitt lymphoma

Acute renal failure in Burkitt lymphoma is commonly the result of tumor lysis syndrome. We present a 15-year-old boy who developed hypertension, seizures, and acute renal failure due to extrinsic compression of the bladder and ureters by a large retrovesical Burkitt lymphoma. The causes of acute renal failure in Burkitt lymphoma and the incidence of acute urinary obstruction in this disease are reviewed.

Delayed methotrexate clearance in a patient with sickle cell anemia and osteosarcoma

A 15-year-old girl with homozygous sickle cell anemia (HbSS) and osteosarcoma is described. Delayed clearance of methotrexate (MTX) after the second course of high-dose MTX (HDMTX) led to the development of renal and hepatic toxicities. Rescue was accomplished with high-dose leucovorin, intravenous carboxypeptidase G2, and thymidine. Although the renal and hepatic abnormalities resolved, focal tonic-clonic seizures developed, accompanied by abnormal brain imaging. Four weeks after this episode, all clinical and biochemical abnormalities resolved. Preexistent end-organ damage associated with HbSS may compromise the ability to deliver high-dose chemotherapy with curative intent in patients with malignant disease.