Prevalence of autoantibodies in pediatric patients with idiopathic pulmonary hemosiderosis: a scoping review of the literature in the period 1980-2021

Idiopathic pulmonary hemosiderosis (IPH) is a rare disease of unknown etiology. Due to the frequent findings of autoimmune antibodies - autoantibodies, immunologic causation of the diffuse alveolar hemorrhage in IPH has been proposed, to assess the prevalence/frequency and type of autoantibodies in pediatric patients with IPH. In addition, the patient demographics, diagnostic modalities used to diagnose IPH, treatment, and outcomes were also evaluated. Scoping review: The PubMed, Medline, and Embase databases were searched with appropriate MeSH terms to identify relevant papers consistent with the defined inclusion criteria. Thirteen observational studies comprising a total of 352 pediatric patients were included in this review. The majority of subjects were girls 217 out of 352 (61.6%). The mean and median ages of patients ranged from 3.1-6.5 years to 2.3-7 years, respectively. In the 10 studies that specified the number of patients in their cohorts with either at least one positive autoantibody or no antibody, the overall prevalence of autoantibodies was 76 out of 288 patients (26.4%). The prevalence of specific antibodies was as follows: ANA, 20.3%; ANCA, 17%; anti-dsDNA, 9.1%; RF, 12%; anti-SMA, 23.2%; and celiac antibodies, 25.9%. Cow's milk protein allergy was present in 16.2% of the children. The significance of an association between IPH and the presence of autoantibodies has not been clarified. The autoantibodies could be suggestive of an overall immune dysregulation rather than causation. However, limited evidence based on a single study suggests that the presence of ANA may be associated with a higher risk of recurrence and worse outcomes. Further research, including prospective studies, will be crucial to explore a possible genetic linkage between vasculitides, systemic rheumatologic diseases, and IPH.

[Evaluation of transfusion hemochromatosis prevalence, SFVTT-01 study: preliminary results of the SFVTT working group]

RATIONAL

Although notification of post-transfusion hemosiderosis is mandatory since 1994 among the French hemovigilance network, it is so far largely under reported.

PATIENTS AND METHODS

We screened 42,443 patients hospitalized for blood diseases in France in 2009 and 2010 and determined which patients had received more than 20 PRC. Among them, we selected those having at least one measure of serum ferritin, and subsequently those which ferritin was greater than or equal to 1000 ng/mL.

RESULTS

Three thousand eight hundred and twelve patients (9%) received more than 20 PRC, 1935 (4.5%) had a ferritin assay, which was increased in 1216 patients (2.9%). Eight hundred and eighty-one patients underwent an hemovigilance report form. Forty-nine percent had low-risk myelodysplasia or acute leukemia, 7% hemoglobinopathies. Hemosiderosis was asymptomatic for 680 patients (77%), serious 188 (88%) and life-threatening for 11 (1%). Two patients died of terminal heart failure. The most severe hemosiderosis (≥ grade 2) were low-risk myelodysplasia and idiopathic aplastic anemia. Ninety-two percent of thalassemia patients and 46% of sickle cell anemia patients received an iron chelator. For low-risk myelodysplastic syndromes and idiopathic aplastic anemia, 228 of the 317 patients whose treatment is known and who could benefit from iron chelation (72%) have not received it.

CONCLUSION

These results encourage seeking optimal transmission of information (over 20 CGR) to the clinician, and prolonging hemovigilance action towards a more comprehensive statement of post-transfusion hemochromatosis.

Focal hemosiderin deposits and β-amyloid load in the ADNI cohort

BACKGROUND

Prevalence and risk factors for focal hemosiderin deposits are important considerations when planning amyloid-modifying trials for treatment and prevention of Alzheimer's disease (AD).

METHODS

Subjects were cognitively normal (n = 171), early-mild cognitive impairment (MCI) (n = 240), late-MCI (n = 111), and AD (n = 40) from the Alzheimer's Disease Neuroimaging Initiative (ADNI). Microhemorrhages and superficial siderosis were assessed at baseline and on all available MRIs at 3, 6, and 12 months. β-amyloid load was assessed with (18)F-florbetapir positron emission tomography.

RESULTS

Prevalence of superficial siderosis was 1% and prevalence of microhemorrhages was 25% increasing with age (P < .001) and β-amyloid load (P < .001). Topographic densities of microhemorrhages were highest in the occipital lobes and lowest in the deep/infratentorial regions. A greater number of microhemorrhages at baseline was associated with a greater annualized rate of additional microhemorrhages by last follow-up (rank correlation = 0.49; P < .001).

CONCLUSIONS

Focal hemosiderin deposits are relatively common in the ADNI cohort and are associated with β-amyloid load.

[GRACILE syndrome--a severe neonatal mitochondrial disorder]

GRACILE syndrome belongs to the Finnish disease heritage, and is caused by a point mutation in the BCS1L-gene encoding a mitochondrial protein. This leads to dysfunction of the complex III in the respiratory chain. Significant fetal growth disturbance is the primary manifestation. Within the first day the newborn infant develops severe lactic acidosis. Hypoglycemia, elevated serum ferritin and conjugated bilirubin values and aminoaciduria imply mitochondrial liver disease and renal tubulopathy. In Finland, the diagnosis is based on the 232A>G mutation in the BCS1L-gene. No specific treatment is available. GRACILE syndrome leads to early death.

Predicted costs of iron-chelators in myelodysplastic syndromes: a 10-year analysis based on actual prevalence and red cell transfusion rates

Consideration of iron-chelation (IC) in transfusion-dependent patients is recommended in most clinical-practice guidelines on myelodysplastic syndromes (MDS). The financial impact of IC on health-care systems is predicted through economic modeling, but an analysis based on actual prevalence is lacking. Here, we have investigated the potential drug-costs and need for IC in a cohort of 189 United Kingdom-based MDS patients diagnosed from 2000 to 2010. Patients with low or intermediate-1 IPSS scores were identified as eligible for IC if ≥24 red cell units (RCU) had been transfused over 12 consecutive months or the transfusion-intensity averaged ≥2 RCU per month. Drug-costs were calculated from the time patients qualified for IC until death or last follow-up. In 159 patients with low/intermediate-1 MDS, survival was superior with a low IPSS score (P = 0.014), age <70 years (P = 0.043), transfusion-independence at diagnosis (P = 0.0056) and transfusion-intensity of <2 RCU per month (P = 0.009). Reflecting the time elapsed since diagnosis, longer survival was observed with a cumulative red cell load of ≥75 U (P = 0.046). By logistic-regression analysis, transfusion-intensity independently predicted survival (P = 0.0035) in low and intermediate-1 risk MDS patients. Forty-one patients fulfilled criteria for consideration of IC. Of these, 6 patients died within 1 month; 35 patients survived for a median of 16 months (range 1-61). Had patients commenced IC, the anticipated drug-costs alone would have been ~$526,880-$2,064,800 over 10 years. The lack of association between cumulative transfusion-load and survival calls for a prospective evaluation of the cost-utility of IC in patients surviving long-term, to enable evidence-based recommendations in MDS management.

Retrospective evaluation of the incidence and severity of hemosiderosis in a large captive lemur population

Significant concern has been generated about the susceptibility of captive lemurs to iron storage disease, which has led some researchers to propose husbandry changes regarding dietary iron. In the current study we sought to determine the history, severity, and prevalence of iron storage disease within a large captive lemur population. Iron concentration and hemosiderin accumulation in a target organ, the liver, were assessed in necropsy specimens from 15 different species (n=153) of lemurs over a 12-yr period at the Duke University Primate Center. Banked liver tissue was used to quantify liver iron concentration (LIC) via neutron activation analysis (NAA). Prussian blue staining was used to accentuate the presence of liver iron for evaluation using an established scoring system. Of the 153 reports examined, 49 (32%) of the animals were considered positive for the presence of hemosiderin in the liver, lymph node, duodenum, and kidney, with 36 of the 49 (73%) showing deposition of iron in the liver. Total iron scores (TIS) ranged from 0.3+/-0.3 in Lemur catta to 33.3+/-1.7 in Cheirogaleus medius. The mean LIC ranged from 209+/-1.4 microg/g wet weight in L. catta to 2957+/-414 microg/g in C. medius. Management practices may have contributed to some of the results observed in this study. Although evidence of excess iron deposition in the liver was present across several species studied, the levels were not as pervasive as previously reported in other captive lemur populations. Hemochromatosis was not observed, and excess iron was not related to the cause of death in any of the animals studied. The current findings suggest that iron overload in lemurs may be more complex than was previously believed.

IRON STORAGE DISEASE IN TAPIRS

Recent studies of serum iron and iron binding capacity have indicated that tapirs could be at risk of developing hemochromatosis. However, in recent surveys of pathologic findings in tapirs, hemochromatosis was not reported as a cause of death. This study reviews necropsy reports from three species of tapir (Baird's tapir [Tapirus bairdii], Malayan tapir [Tapirus indicus], and Brazilian tapir [Tapirus terrestris]) at the Philadelphia Zoological Garden between 1902 and 1994. Twelve cases of hemosiderosis, including fatal hemochromatosis in two Baird's tapirs, were found among 19 cases examined histologically. Hemochromatosis has previously been reported in the horse, rhinoceros, and in one Brazilian tapir. Dietary factors were investigated but could not be confirmed to have contributed to the incidence of hemosiderosis and hemochromatosis in the three species of tapir in the Philadelphia Zoological Garden collection.

Bone Marrow Transplantation in Adults with Thalassemia: Treatment and Long-Term Follow-Up

Current regular blood transfusion programs and chelation treatment have considerably improved survival of patients with thalassemia, which resulted in a larger proportion of adult patients. However, disease- and treatment-related complications in these patients progress over time, causing severe morbidity and shortened life expectancy. Stem cell transplantation still remains the only cure currently available for patients with thalassemia. This study updates transplant outcomes in 107 adult patients with median age of 22 years (range, 17-35 years) who received bone marrow transplantation (BMT) from human leukocyte antigen (HLA)-identical related donors between 1988 and 1996 (group A) and describes the results of BMT in 15 adult patients with median age of 21 years (range, 17-31 years) who were treated with a new treatment protocol (Protocol 26) between 1997 and 2003 (group B). The probability of survival, event-free survival, nonrejection mortality, and rejection for group A patients were 66%, 62%, 37%, and 4%, respectively, with a median follow-up of 12 years (range, 8.3-16.2 years). Group B patients treated with the new protocol had some improvement in thalassemia-free survival (67%) and lower transplant-related mortality (27%) than that of previous protocols. However, transplant-related mortality in these high-risk patients remains elevated. Current myeloablative BMT in adult patients is characterized by higher transplant-related toxicity due to an advanced phase of disease. Although this new approach to transplant adult patients with a reduced-dose intensity-conditioning regimen has improved thalassemia-free survival, transplant-related mortality in these high-risk patients remains elevated.

Frequency and severity of tracheal wash hemosiderosis and association with underlying disease in 96 cats: 2002-2003

BACKGROUND

Hemosiderophages may be found in feline tracheal wash specimens in association with various disease conditions, including heart failure, trauma, infection, foreign body migration, lung lobe torsion, pulmonary embolism or infarction, neoplasia, and bleeding diathesis. Based on observations in our laboratory, we hypothesized that tracheal wash specimens from cats with asthma also frequently contain hemosiderophages, even in the absence of other known causes of pulmonary hemorrhage.

OBJECTIVES

The purpose of this study was to determine the frequency and severity of hemosiderosis in tracheal wash fluid from cats with various diseases, including asthma.

METHODS

Feline tracheal wash fluid specimens submitted for cytologic evaluation between March 2002 and August 2003 were included in the study. One hundred and one specimens from 96 cats were examined with both Wright's-Giemsa and Prussian blue stains. Cats were assigned to 6 disease categories: feline asthma, pneumonia, pulmonary neoplasia, rhinitis, heart disease, and other disorders. Based on the percentage of Prussian blue-positive macrophages, hemosiderosis was categorized as negative (0%), mild (<20%), moderate (21-50%), or marked (>50%).

RESULTS

The frequency of tracheal wash hemosiderosis in the study population was 63.5% (61/96); hemosiderosis was mild (29/96, 30.2%), moderate (22/96, 22.9%), or marked (10/96, 10.4%). Hemosiderosis was found in 85.7% (6/7) of cats with rhinitis, 78.6% (11/14) of cats with pulmonary neoplasia, 75.0% (27/36) of cats with asthma, 71.4% (5/7) of cats with primary or concurrent heart disease, 25.0% (5/20) of cats with pneumonia, and 66.7% (12/18) of cats with other disorders. In cats with asthma, hemosiderosis was usually mild to moderate and frequently was accompanied by increased eosinophils.

CONCLUSIONS

The results of this study confirm that hemosiderosis is a common finding in tracheal wash specimens collected from cats with diverse disease conditions, including feline asthma syndrome.

Common respiratory manifestations of food allergy: a critical focus on otitis media

Previous investigations have established the pathogenic role of food allergy in respiratory tract symptoms, which rarely occur in isolation. Specific foods have been implicated in these reactions. The role of food allergy in otitis media is controversial, probably uncommon, and further studies are needed. Food-induced asthma is more common in young pediatric patients, especially those with atopic dermatitis. Asthma induced by food allergy is considered a risk factor for fatal and near-fatal anaphylactic reactions. Moreover, food allergy can elicit airway hyperreactivity and asthmatic responses. Therefore, evaluation for food allergy should be considered among patients with recalcitrant or otherwise unexplained acute severe asthma exacerbations; asthma triggered by ingestion of particular foods; and asthma and other manifestations of food allergy (eg, anaphylaxis, moderate to severe atopic dermatitis).

Idiopathic pulmonary haemosiderosis revisited

Idiopathic pulmonary haemosiderosis is a rare cause of diffuse alveolar haemorrhage of unknown aetiology. It occurs most frequently in children, has a variable natural history with repetitive episodes of diffuse alveolar haemorrhage, and has been reported to have a high mortality. Many patients develop iron deficiency anaemia secondary to deposition of haemosiderin iron in the alveoli. Examination of sputum and bronchoalveolar lavage fluid can disclose haemosiderin-laden alveolar macrophages (siderophages), and the lung biopsy shows numerous siderophages in the alveoli, without any evidence of pulmonary vasculitis, nonspecific/granulomatous inflammation, or deposition of immunoglobulins. Contrary to earlier reports, corticosteroids alone or in combination with other immunosuppressive agents may be effective for either exacerbations or maintenance therapy of idiopathic pulmonary haemosiderosis.

Acute idiopathic pulmonary hemorrhage among infants. Recommendations from the Working Group for Investigation and Surveillance

This report presents CDC's recommended case definitions and surveillance practices for Acute Idiopathic Pulmonary Hemorrhage (AIPH). In 1994 and 1997, CDC reported clusters of acute pulmonary hemorrhage (APH) among infants in Cleveland, Ohio. Subsequent reviews of these investigations identified shortcomings in the conduct of the studies and concluded that the investigations did not prove an association between APH among infants and exposure to molds. In response to recommendations from these reviews, with assistance of external consultants, CDC staff developed a plan to conduct surveillance for and investigation of AIPH. In developing this response, CDC recommends a definition for a clinically confirmed case of AIPH among infants on the basis of evidence of blood in the airway, age </=1 year, absence of medical conditions related to pulmonary hemorrhage, and severe acute respiratory distress or respiratory failure. CDC recommends that pediatric intensive care units (PICUs) report cases that meet the CDC case definition to state health departments. CDC staff will study the number of reported cases of AIPH among infants and also review the Cleveland and Chicago case series to determine the degree to which the present case definition applies to them. If these reviews establish that AIPH among infants is a public health problem, on the basis of its magnitude or geographic or temporal distribution, targeted case surveillance will be initiated based on the distribution of cases. CDC staff will work with state and local health departments to investigate reported clusters of cases of AIPH among infants.

Clinical profile of 30 infants with acute pulmonary hemorrhage in Cleveland

Between 1993 and 2000, 30 infants were hospitalized with acute pulmonary hemorrhage at Rainbow Babies and Children's Hospital in Cleveland. Most infants presented with severe pulmonary symptoms requiring intensive support, but a few infants had less severe hemorrhage. Three quarters of the patients required ventilator support and blood transfusions. Eleven patients had transitory hemoglobinuria. Five patients died, but infants who survived did well. There are currently no specific treatment modalities, although we have advised moving to a different home and avoiding environmental tobacco smoke. Subsequently, rebleeding from the lower respiratory tract has decreased from 5 of 7 infants to 1 in 21. On the basis of decreased subsequent fatal hemorrhage, high dose glucocorticoids seem to be of some value. Several patients revealed continued low-grade alveolar hemorrhage for months after their initial bleed, even after removal from their original home environments.

Update: Pulmonary hemorrhage/hemosiderosis among infants--Cleveland, Ohio, 1993-1996

A review within CDC and by outside experts of an investigation of acute pulmonary hemorrhage/hemosiderosis in infants has identified shortcomings in the implementation and reporting of the investigation described in MMWR and detailed in other scientific publications authored, in part, by CDC personnel. The reviews led CDC to conclude that a possible association between acute pulmonary hemorrhage/hemosiderosis in infants and exposure to molds, specifically Stachybotrys chartarum, commonly referred to by its synonym Stachybotrys atra, was not proven. This report describes the specific findings of these internal and external reviews.

Frequency of pulmonary hemosiderosis in Eastern North Carolina

Pulmonary hemosiderosis has been attributed to airborne fungi in water-damaged homes in studies of a cluster of cases in infants and children in Cleveland, Ohio, in 1997. We have searched for such emerging infectious agents in the Coastal Plain of North Carolina, which is subject to intermittent flooding. Pulmonary tissue from 206 infants and young children whose deaths had been investigated from October 1978 to September 1996 was retained at East Carolina University School of Medicine. Ages ranged from premature newborns to 49-months. One hundred and ten deaths were attributed to sudden infant death syndrome (SIDS). New sections were cut and analyzed using hematoxylin and eosin, Prussian blue for iron, and Gomori methenamine silver for fungal organisms. Twenty-three infants and children had iron-containing macrophages. Sixteen of these had underlying illnesses, but 4 were originally diagnosed as SIDS. Only one of these had sufficient hemosiderosis to be considered as having pulmonary hemosiderosis and no fungi were present. One case without iron had fungi and was not originally diagnosed as SIDS. The single case of pulmonary hemosiderosis found in this rural area is not similar to the cluster in Cleveland. The study identifies no fungal organisms as emerging infectious diseases in this area.

Overview of investigations into pulmonary hemorrhage among infants in Cleveland, Ohio

Idiopathic pulmonary hemorrhage was diagnosed in 37 infants in the Cleveland, Ohio, area between 1993 and 1998. This rare disorder has been related to 12 deaths, including 7 originally thought to be sudden infant death syndrome. Thirty of the infants were African American, all of whom lived in a limited geographic area of eastern metropolitan Cleveland, an area of older housing stock. An investigation led by the Centers for Disease Control and Prevention has found an association with household exposure to a toxigenic mold, Stachybotrys chartarum, and other fungi. The rapidly growing lungs of young infants appear to be especially vulnerable to the toxins made by toxigenic molds. Environmental tobacco smoke was frequently present in the infants' homes and may be a trigger precipitating the acute bleeding. Stachybotrys, although not thought to be a common mold, is known to have a wide geographic distribution. An additional 101 cases of acute, idiopathic pulmonary hemorrhage have been reported in infants in the United States over the past 5 years. In this overview, the investigations are summarized, the clinical profile is described, the toxicity of S. chartarum is discussed, and pathophysiologic concepts are presented.

Study of toxin production by isolates of Stachybotrys chartarum and Memnoniella echinata isolated during a study of pulmonary hemosiderosis in infants

A cluster of cases of pulmonary hemosiderosis among infants was reported in Cleveland, Ohio, during 1993 and 1994. These unusual cases appeared only in infants ranging in age from 1 to 8 months and were characterized by pulmonary hemorrhage, which caused the babies to cough up blood. A case-control study identified major home water damage (from plumbing leaks, roof leaks, or flooding) as a risk factor for development of pulmonary hemorrhage in these infants. Because of an interest in the possibility that trichothecene mycotoxins might be involved in this illness, a number of isolates of Stachybotrys chartarum were grown in the laboratory on rice, and extracts were prepared and analyzed both for cytotoxicity and for specific toxins. Two isolates of Memnoniella echinata, a fungus closely related to S. chartarum, were also included in these studies. S. chartarum isolates collected from the homes were shown to produce a number of highly toxic compounds, and the profiles of toxic compounds from M. echinata were similar; the most notable difference was the fact that the principal metabolites produced by M. echinata were griseofulvins.

Acute pulmonary hemorrhage in infants associated with exposure to Stachybotrys atra and other fungi

BACKGROUND

A geographic cluster of 10 cases of pulmonary hemorrhage and hemosiderosis in infants occurred in Cleveland, Ohio, between January 1993 and December 1994.

STUDY DESIGN

This community-based case-control study tested the hypothesis that the 10 infants with pulmonary hemorrhage and hemosiderosis were more likely to live in homes where Stachybotrys atra was present than were 30 age- and ZIP code-matched control infants. We investigated the infants' home environments using bioaerosol sampling methods, with specific attention to S atra. Air and surface samples were collected from the room where the infant was reported to have spent the most time.

RESULTS

Mean colony counts for all fungi averaged 29 227 colony-forming units (CFU)/m3 in homes of patients and 707 CFU/m3 in homes of controls. The mean concentration of S atra in the air was 43 CFU/m3 in homes of patients and 4 CFU/m3 in homes of controls. Viable S atra was detected in filter cassette samples of the air in the homes of 5 of 9 patients and 4 of 27 controls. The matched odds ratio for a change of 10 units in the mean concentration of S atra in the air was 9.83 (95% confidence interval, 1.08-3 X 10(6)). The mean concentration of S atra on surfaces was 20 X 10(6) CFU/g and 0.007 x 10(6) CFU/g in homes of patients and controls, respectively.

CONCLUSION

Infants with pulmonary hemorrhage and hemosiderosis were more likely than controls to live in homes with toxigenic S atra and other fungi in the indoor air.

Iron-overload disease in infants involving fetal growth retardation, lactic acidosis, liver haemosiderosis, and aminoaciduria

BACKGROUND

Several cases of a distinctive lethal neonatal disorder have been found in the Children's Hospital, Helsinki, Finland. However, the combination of presenting features is not typical of any known metabolic disease. We have analysed all known cases of this disorder in the hospital since 1965 and in Finland since 1990 to define clinical features of the disease.

METHODS

We studied 17 newborn infants with severe growth retardation from 12 Finnish families and traced their genealogy. In addition to routine clinical studies, diagnostic workup included analysis of respiratory-chain function in isolated muscle mitochondria and necropsy specimens, pyruvate dehydrogenase complex activities in fibroblasts, analysis of aminoacids and organic acids in urine, staining of tissue samples for iron, and assay of liver iron content.

FINDINGS

The infants were born near term (mean 37.8 [SD 3] gestational weeks) but were severely growth retarded (birthweight 1690 [460] g--ie, -3.8 [SD 0.6] SD score for gestational age). By age 24 h, mean pH was 7.00 (0.12), lactate 12.2 (7.5) mmol/L, and pyruvate 121 (57) micromol/L. All had aminoaciduria and failed to thrive; nine died neonatally (age 2-12 days), and eight died in infancy (1-4 months). The liver of four infants showed microscopic haemosiderosis and increased iron content (2.8-5.5 mg iron/g dry weight). In those four infants serum ferritin concentration (1260-2700 microg/L) and transferrin saturation (61-100%) were high, transferrin concentration (0.54-0.76 g/L) was low.

INTERPRETATION

We describe a previously unrecognised clinical picture of a genetic disease, which presents with fetal growth retardation and lactic acidosis after birth. Genealogical studies indicate an autosomal-recessive mode of inheritance for this disease, which is distinct from other lactic acidoses, neonatal haemochromatosis, and hepatitis. The diagnostic criteria are: fetal growth retardation; severe lactic acidosis; aminoaciduria; iron overload with haemosiderosis of the liver, increased serum ferritin concentration, hypotransferrinaemia, and increased transferrin iron saturation. Organ dysfunction may be partly due to the toxic effects of free iron.

Tuberculosis and iron overload in Africa: a review

Both pulmonary tuberculosis and dietary iron overload are common conditions in sub-Saharan Africa. The incidence of tuberculosis has increased markedly over the last decade, primarily as a result of the rapid spread of infection with the human immunodeficiency virus (HIV). Dietary iron overload affects up to 10% of adults in rural populations and is characterized by heavy iron deposition both in parenchymal cells and in macrophages. Mycobacterium tuberculosis grows within macrophages and, at the same time, the antimicrobial function of macrophages is important in the body's defence against tuberculosis. In vitro, the loading of macrophages with iron reduces the response of these cells to activation by interferon-gamma and diminishes their toxicity against micro-organisms. In the clinical setting, dietary iron overload appears to increase the risk for death from tuberculosis even in the absence of the acquired immunodeficiency syndrome. The combination of dietary iron overload and infection with the HIV, with impaired function of both macrophages and T-cells, may make patients especially vulnerable to tuberculosis. It is possible that the prevention and treatment of dietary iron overload could contribute to the control of tuberculosis in African populations.

Pulmonary hemorrhage in infants and children

Following a brief presentation of important clinical concepts regarding pulmonary hemorrhage in infants and children, recent reports on secondary and immune-related disorders causing acute pulmonary hemorrhage are reviewed. Idiopathic pulmonary hemosiderosis is updated noting the compilation of Japanese cases and current treatments. The recent increase in idiopathic pulmonary hemorrhage and hemosiderosis in young infants, particularly in Cleveland, is discussed along with management suggestions and an apparent relationship to some sudden infant death syndrome cases.

Hepatic hemosiderosis in common marmosets, Callithrix jacchus: effect of diet on incidence and severity

We examined the effect of dietary iron concentration on the incidence of hepatic hemosiderosis in common marmosets (Callithrix jacchus) and assessed the impact of hemosiderosis on animal health. Thirteen young adult common marmosets were fed nutritionally balanced natural-ingredient diets formulated to contain either 100 or 500 ppm of iron. Six were fed the low-iron and seven received the high-iron diet. Baseline blood values and liver iron content were determined for each animal. Animals were weighted monthly, blood work (hematologic analysis, serum iron concentration, total iron-binding capacity, percent of transferrin saturation) was performed semi-annually, and liver biopsies for iron analysis were obtained after marmosets had consumed the test diets for 13 months or at necropsy. Midway in study, the high-iron diet was reformulated to contain 350 ppm of iron because of the death of a male which had consumed that diet for 7 months. Four of seven marmosets fed the high-iron diet died during the first year of the study, compared with one death in the low-iron cohort. The mean increase in liver iron content of the marmosets fed the high-iron diet was 6,371 micrograms/g, dry weight analysis. In contrast the low-iron cohort had a mean decrease of 621.5 micrograms/g. These results indicate that liver iron content can be affected by dietary iron intake. The increased mortality in the marmosets fed the high-iron diet also suggests that hepatic hemosiderosis can be detrimental to marmoset health.

Update: pulmonary hemorrhage/hemosiderosis among infants--Cleveland, Ohio, 1993-1996

In November 1994, private physicians and public health officials in Cleveland, Ohio, and CDC reported a cluster of eight cases of acute pulmonary hemorrhage/hemosiderosis that had occurred during January 1993-November 1994 among infants in one area of the city. Two additional cases were identified in December 1994. All 10 infants lived within seven contiguous postal tracts in eastern metropolitan Cleveland. Pulmonary hemorrhages recurred in five of the infants after they returned to their homes shortly after hospital discharge; one infant died as a result of pulmonary hemorrhage. This report summarizes the findings of the follow-up investigation, including a case-control study and an assessment by the county coroner of cases of infant death. These findings documented an association between acute pulmonary hemorrhage/hemosiderosis in this cluster of cases and mold growth in their water-damaged homes.

Associations of iron overload in Africa with hepatocellular carcinoma and tuberculosis: Strachan's 1929 thesis revisited

We analyzed data from the first study of iron overload in Africans, conducted between 1925 and 1928, to determine whether this common condition is associated with death from hepatocellular carcinoma and/or tuberculosis. In the original study, necropsies were performed on 714 adult blacks from southern Africa. Hepatic and splenic iron levels were measured semiquantitatively in 604 subjects and one of five iron grades was assigned. We examined death from hepatocellular carcinoma or from tuberculosis and the variables of age, sex, the presence of cirrhosis or other diagnoses that might be influenced by iron status, and tissue iron grades. Nineteen percent of men and 16% of women had the highest grade of hepatic iron. After adjustment for the presence of cirrhosis, hepatic iron grade was the variable most significantly associated with death from hepatocellular carcinoma (P = .021). The odds of death from hepatocellular carcinoma in subjects with the highest grade of hepatic iron was 23.5 (95% confidence interval, 2.1 to 225) times the odds in subjects with the three lowest grades. Splenic iron was the variable most significantly associated with death from tuberculosis (P <.0001). The odds of death from tuberculosis with the highest grade of splenic iron was 16.9 (4.8 to 59.9) times the odds with the two lowest grades. These findings suggest that iron overload in black Africans may be a risk factor for death from hepatocellular carcinoma and for death from tuberculosis.

Hepatocellular carcinoma and African iron overload

Both hepatocellular carcinoma (HCC) and iron overload are important health problems in Africa. Chronic hepatitis B virus (HBV) infection is recognised as a major risk factor for HCC, but iron overload in Africans has not been considered in pathogenesis. Up to half the patients with HCC in Africa do not have any recognised risk factors such as preceding chronic HBV infection, and other risk factors remain unidentified. HCC is an important complication of HLA-linked haemochromatosis, an iron loading disorder found in Europeans. It is proposed that African iron overload might also be a risk factor for HCC.

Acute pulmonary hemorrhage/hemosiderosis among infants--Cleveland, January 1993-November 1994

Hemosiderosis is an uncommon childhood disease characterized by spontaneous pulmonary hemorrhage often associated with iron deficiency anemia. During January 1993-November 1994, eight cases of acute pulmonary hemorrhage/hemosiderosis were diagnosed among infants at a children's referral hospital in Cleveland. In comparison, during 1983-1993, a total of three cases of pulmonary hemosiderosis were diagnosed among infants and children at this hospital. This report summarizes the preliminary results of the ongoing epidemiologic, clinical, and laboratory investigations by pediatric pulmonologists in Cleveland, the Ohio Department of Health, the City of Cleveland Department of Public Health, the Cuyahoga County Board of Health, and CDC.(ABSTRACT TRUNCATED AT 250 WORDS)

The spectrum of chronic liver disease in renal transplant recipients

Chronic liver disease has been reported to be an important cause of late morbidity and mortality in renal transplant recipients. We have examined the prevalence and nature of chronic liver disease among 538 patients with functioning renal allografts managed at the Western Infirmary, Glasgow, between 1980 and 1989. Thirty-seven patients (7 per cent) satisfied biochemical criteria for chronic liver dysfunction. Liver biopsies were obtained from 24 of these, and autopsy tissue was available from three other patients. Chronic hepatitis of variable severity was present in 15 patients, haemosiderosis in 12 patients and nodular regenerative hyperplasia in five patients. Nineteen patients (51 per cent) had serological evidence of infection with the hepatitis C virus, and one of these developed chronic hepatitis B and D infection as well. Although a variety of chronic liver diseases occurred in our transplant population, the frequency of serious sequelae from liver dysfunction was much lower than that reported from transplant centres in other countries.

Idiopathic pulmonary haemosiderosis in Swedish children

During the 3 decades 1950-1979 onset of idiopathic pulmonary haemosiderosis occurred in 10 Swedish children. Complete records were available from the eight children with onset during 1960-1979, which indicates that the yearly risk of onset is 0.24 case per million children. The first symptoms started at the mean age of 5.8 years (range: 10 months-11 years). From the beginning all children had a severe microcytic, hypochromic, sideropenic anaemia. Pulmonary symptoms were present from the beginning in four children (but haemoptysis in only one) and developed in the remaining children after 1 1/2-2 1/2 years. Various therapeutical regimens were tried. Iron therapy seemed of temporary beneficial effect and most children seemed to benefit from prednisone therapy during disease bouts, although the effect of the therapy in the long run could not be determined. The four children with onsets during the 1960s died of their disease after 2-13 years. The four children with onset during the 1970s are still alive. One of them--a 20-year-old female, has for two years complete clinical remission and has normalized haematological, X-ray and pulmonary function data.

Epidemiologic observations in idiopathic pulmonary hemosiderosis

We did an epidemiologic survey of 30 children in whom idiopathic pulmonary hemosiderosis was diagnosed. Eighteen patients had died; 12 patients were still living. The majority of the cases were diagnosed in between 1962 and 1971, mainly in the spring and fall. Eighty percent of the patient lived in villages, whereas only 30% of the total population resided in the same type of rural area. Only one (5%) of the deceased children lived in the city, whereas four (33%) of the living children were city dwellers. The socioeconomic conditions were poor, and in 50% of the cases continuous exposure to highly toxic insecticides was elicited by history and investigation of housing conditions. The incidence of newly diagnosed cases decreased with the improvement of living conditions and the prohibition of the use of certain insecticides. We believe that environmental factors, perhaps insecticides, may cause idiopathic pulmonary hemosiderosis in genetically predisposed persons. An epidemiologic history and genetic investigation should be included in the evaluation of patients with any disease when the cause is obscure.