Short-course oral prednisone therapy in children presenting with acute immune thrombocytopenic purpura (ITP)

Immune thrombocytopenic purpura (ITP) is a disorder for which management remains controversial. The ongoing goal is to define the minimal therapy required for children with acute ITP. A pilot study of short-course oral prednisone (4 mg⁻¹ kg⁻¹ d⁻¹ for 4 d with no tapering) was undertaken in 25 consecutive children with acute ITP and platelet counts under 20 × 10⁹ 1⁻¹. Of the 25 children, 22 responded to the prednisone therapy by achieving a platelet count higher than 20 × 10⁹ 1⁻¹ within 1 week of commencing treatment. This regimen was found to be safe, inexpensive and effective in increasing the platelet count of children to a haemostatically safe level.     

Phenotypes of Peripheral Blood Lymphocytes during Acute Hepatitis A

ABSTRACT. We investigated peripheral blood lymphocyte phenotypes of 74 patients at weekly intervals during the course of acute hepatitis A. In the second week after onset of jaundice, a significant elevation of total lymphocytes was observed (4096 × 10⁶± 1003 × 10⁶/l vs. controls 3038 × 10⁶± 1208 × 10⁶/l, p < 0.005). However, no change in the relative percentages of B-cells (CD20+), T-cells (CD3+ or CD2+), or T-cell subpopulations (CD4+ helper cells and CD8+ suppressor cells) could be demonstrated during the course of the disease. Activated T-cells (CD3+DR+) were elevated during the first week (204 × 10⁶± 134 × 10⁶/l vs. normal 91 × 10⁶± 54 × 10⁶/l, p <0.005) and during the second week (202 × 10⁶± 82 × 10⁶/l, p < 0.0005) after onset of disease and returned to normal values until the third week. Cells expressing phenotypes of lymphocytes capable of exerting non-MHC-restricted cellular cytotoxicity, i.e. Natural Killer cell activity (CD57+, CD16+, and CD56+) were significantly elevated in percentage in the first week of disease, as compared to controls (CD57: 14.5 ± 7.0% vs. 9.3 ± 5.8%, p <0.05; CD16: 13.4 ± 7.3 vs. 9.5 ± 5.1%, p < 0.05; CD56: 10.5 ± 3.5% vs. 8.0 ± 1.5%, p < 0.005). Also the absolute numbers of these lymphocyte subpopulations were found to be elevated during the first and second week. The increase in NK cells in the initial phase of acute hepatitis A suggests an important role of these cells in the first line of defence in this disease.     

Platelet function in autoimmune (idiopathic) thrombocytopenic purpura

Platelets play an essential role in the formation of haemostatic plugs. The quantitative defect of platelets in autoimmune (idiopathic) thrombocytopenic purpura (ITP) can result in bleeding complications, but most ITP patients have platelets with normal or enhanced function. Platelets in ITP are large, young, so-called "stress" platelets with increased platelet-associated autoimmune antibody (immunoglobulin G). Young stress platelets are more functional platelets, and their presence may account for bleeding times in ITP patients that are shorter than would be predicted on the basis of the patients' (low) platelet counts. Some ITP patients have significant mucocutaneous bleeding with platelet counts >50 × 10⁹ l⁻¹; this may be due to qualitative platelet dysfunction (e.g. brought about by inhibitory antiplatelet autoantibodies).     

Early and Late Neutropenia in Children Treated with Cotrimoxazole (Trimethoprim-Sulfamethoxazole)

ABSTRACT. The incidence of hematologic abnormalities was evaluated in 120 children with otitis media treated respectively with cotrimoxazole (trimethoprim-sulfamethoxazole) (group 1), cotrimoxazole plus folinic acid (group 2) and amoxicillin (group 3) in therapeutic doses for ten days. Only eosinophilia (an absolute count ≥0.5×10⁹/l) (group 1 = 10%, 2=5%, 3=7.5%) and neutropenia (polymorphonuclear neutrophilic leucocyte count ≤1.5×10⁹/l) (group 1=35%, 2=17.5%, 3=13.3%) were noted. Early neutropenia (evident on the 5th day of therapy) occurred in all the treatment groups, thus it is not related to cotrimoxazole administration and in most cases neutrophil count reversed to normal in few days without drug discontinuation. Late neutropenia (evident after 10 days of treatment) appeared only in cotrimoxazole treated children ( p <0.05). No superimposed bacterial infection was demonstrated in any case. Late neutropenia seems to be strictly related to the sequential blockage of folinic acid metabolism and can be prevented by the concomitant administration of folinic acid.     

METHOTREXATE IN THE PLASMA AND CEREBROSPINAL FLUID OF CHILDREN TREATED WITH INTERMEDIATE DOSE METHOTREXATE

ABSTRACT. Rechnitzer, C, Scheibel, E. and Hendel, J. (University Clinic of Paediatrics, Rigshospitalet and Department of Clinical Chemistry, Finsen Institute, Copenhagen, Denmark). Methotrexate in the plasma and cerebrospinal fluid of children treated with intermediate dose methotrexate. Acta Paediatr Scand, 70:615,.–Serious complications can follow treatment with intermediate dose methotrexate of acute lymphoblastic leukemia in childhood. Toxicity has been shown to be correlated to plasma methotrexate concentrations. During intravenous infusions of methotrexate (500 mg/m²) the mean concentrations achieved 1 to 4¹/₂ hours after the start of infusion were 1.3×10^-7 mol/l in cerebrospinal fluid and 1.7×10^-5 mol/1 in plasma. At 72 hours after start of methotrexate infusion, plasma methotrexate concentrations were significantly higher in cases with symptoms of toxicity. In all the children who developed toxic symptoms 72-hour plasma methotrexate concentration was above 1×10^-7 mol/l. Assuming that leucovorin is given 48 hours after the start of methotrexate infusion, 72-hour plasma methotrexate is suitable for detection of patients at risk for toxicity. In children treated with intermediate dose methotrexate we therefore recommend estimating plasma methotrexate concentration 72 hours after the start of infusion, and instituting supplementary leucovorin when plasma methotrexate concentration exceeds 1×10^-7 mol/l.     

High-dose Intravenous Gammaglobulin for Neonatal Alloimmune Thrombocytopenia in Twins

ABSIRACT. Pietz J., Kiefel V., Sontheimer D., Kobialka B., Linderkamp O and Mueller-Eckhardt C. (Division of Neonatology, Children's Hospital, University of Heidelberg, and Institute of Clinical Immunology and Transfusion Medicine, University of Giessen, FRG). High-dose intravenous gammaglobulin for neonatal alloimmune thrombocytopenia in twins. Acta Paediatr Scand 80: 129, 1991.
We report the successful treatment of neonatal alloimmune thrombocytopenia with repeated infusions of high-dose immunoglobulin G (400 mg/kg/d for 5 days) in twins. Platelet counts increased within 3 days from less than 20×10⁹/1 to more than 70 × 10⁹/1. The first twin survived without neurological or other sequelae. The second twin had probably developed intracranial hemorrhage (ICH) in utero. This infant developed long-term neurological sequelae with blindness, cerebral palsy and infantile spasms. Implications of the therapeutic approach and prevention of severe complications in pregnancies with known risk for neonatal alloimmune thrombocytopenia are discussed.     

Unrelated cord blood transplantation in children with severe congenital neutropenia

Abstract:  SCN is an inherited hematological disorder with severe neutropenia and recurrent infections. Although there are some reports that recombinant rhG-CSF improves clinical outcome, allogeneic HSCT appears to be the only curative treatment for these patients. We report here two children with SCN successfully treated by CBT from unrelated donors. They were refractory to rhG-CSF treatment and have no identical family donor. Bu + CY were given as conditioning. Case 1 and Case 2 received 6/6 and 5/6 HLA-matched unrelated umbilical cord blood, respectively. The number of infused nucleated cells was 6, 18 × 10⁷/kg and CD34⁺  cell number was 3, 74 × 10⁵/kg in Case 1. Those cell numbers were 8, 8 × 10⁷/kg and 5, 34 × 10⁵/kg for Case 2, respectively. Neutrophil/platelet engraftments were 45/49 days in Case 1 and 24/36 days in Case 2. Grade II cutaneous acute GVHD was seen in Case 2 that was treated successfully with prednisolone. Both patients are well with normal hematological findings and full donor chimerism for post-transplant 20 and 24 months, respectively. We conclude that UCB can be considered as a safe source of stem cell in patients with SCN who need urgent HSCT.     

Transfusion-associated fall in platelet count in very low birthweight infants

Abstract Thirty-three infants with a birthweight of less than 1500 g were investigated retrospectively for the incidence and aetiology of thrombocytopenia occurring during the first week of life. The platelet count fell below 100 × 10⁹/l in 16 infants (48%). There was a moderately strong inverse correlation between the platelet count at its nadir during the first week or the first value below 100 × 10⁹/l and the percentage of blood volume transfused prior to this ( r =−0.61; P < 0.0001). When the platelet count was expressed as a percentage of the initial count the correlation was −0.74 ( P < 0.0001). The results were not affected by the elimination of the 10 infants with clinical conditions regarded as a probable cause of thrombocytopenia. The fitted least-squares regression line suggests that a transfusion equal to 10% of the blood volume on average reduced the platelet count by 19 × 10⁹/l or by 7% in these very low birthweight infants during the first week of life.     

Increased Ig-null B lymphocytes in the peripheral blood of pediatric solid organ transplant recipients with elevated Epstein-Barr viral loads

Abstract:  In this study, the characteristics of Ig-null B cells in high viral load carriers were examined by four-color flow cytometry. The frequency of Ig-null B cells in patients with high, low or undetectable virus loads was found that while patients with a high load had more Ig-null cells, these cells were also present in the low and undetectable load groups. As Ig-null cells from patients with no viral load were EBV-negative, EBV infection was not absolutely required for the generation or survival of Ig-null cells. Ig-null cells were CD19⁺, sIg^-, CD5⁻, CD10⁻, CD27⁻, CD23⁻, CD38⁻, and CD69⁻ with variable surface expression of CD20 and CD40. Ig-null cells did not have a proliferating cell phenotype (Ki67^-) and a high proportion were HLA class I^- and class II^-. Virus copy number in CD19⁺ Ig-null cell populations may be much higher than in CD19⁺ Ig⁺ cell populations. EBV infected Ig-null cells were common in blood specimens from pediatric solid organ transplant recipients and infected Ig-null cells may pose potential problems for immunotherapies that target infected B cells directly.     

Decreased ferritin levels, despite iron supplementation, during erythropoietin therapy in anaemia of prematurity

Erythropoietin (rHuEPO) therapy has been shown to be beneficial in preventing and treating anaemia of prematurity and to decrease the need for blood transfusions. There is, however, only scanty data on the effect of rHuEPO therapy on iron metabolism. We studied 29 preterm infants (age 34 ± 14 days) who were randomly assigned to receive either rHuEPO 900 U kg^-1 week^-1 with 6 mg kg^-1 day^-1 of iron for 4 weeks ( n= 15) or no therapy. The following parameters were evaluated and compared between and within groups at the beginning, during and at the end of the study: Haematocrit (SI), reticulocytes (10⁹μgl^-1), serum ferritin (μg1^-1) and iron (μmol 1^-1). The results were as follows. At the baseline, erythropoietin levels were similar in both groups: 7.2 ± 5.6 versus 6.2 ± 3.2 mU ml^-1 (NS). In the treated infants the haematocrit remained stable during the study and was significantly higher than in the control group by the end of the study: 0.34 ± 0.03 versus 0.28 ± 0.05 ( p = O.001). rHuEPO therapy increased the reticulocyte count from 130 ± 70 to 430 ± 200 ( p = 0.0002). However, rHuEPO therapy depleted both serum ferritin and it-on levels from 321 ± 191 to 76 ± 58 $uMgl^-1 ( p = 0.04) and from 18 ± 5 to 13 ± 4 μmoll^-1 ( p = 0.03), respectively. We conclude that rHuEPO therapy prevented anaemia and its sequelae; however, serum ferritin and iron levels were depleted. We suggest that the effect of rHuEPO may be further increased by higher iron supplementation.     

A Population-Based Study of Children with Standard Risk Acute Lymphoblastic Leukemia in the Five Nordic Countries

ABSTRACT. Two hundred and thirty children with standard risk acute lymphoblastic leukemia (ALL) were diagnosed during a period of 3 years from July 1, 1981 to June 30,1984 in the five Nordic countries. Criteria for standard risk ALL were age above 2.0 and below 10 years, WBC <20×10⁹/l, no evidence of CNS-involvement, mediastinal mass or T- or B-cell leukemia. The children were treated without prophylactic CNS irradiation, the majority (200 patients) according to two treatment programs. Follow-up of the entire group after a minimum of 30 months showed 64% of the children living in complete continuous remission with a probability of event-free survival of 0.60. The treatment results are not entirely satisfactory and intensification of therapy is required. A subgroup of patients with WBC between 10 and 20×10⁹/I and with adverse prognosis was identified, justifying a change of the present criteria for risk grouping.     

Intranasal versus intravenous administration of midazolam to children undergoing small bowel biopsy

Sixty-three children under the age of 9 years were randomized to receive intravenous (group A, n = 33) or intranasal (group B, n = 30) midazolam as sedation for small bowel biopsy. Mean doses of midazolam given to produce adequate sedation were 0.31 mg (kg body weight)⁻¹ in group A and 0.34 mg (kg body weight)⁻¹ in group B (NS). Four children in group A and 10 children in group B required additional doses to maintain adequate sedation throughout the biopsy procedure (p <0.05). There was no significant difference between the groups regarding the median procedure time (7 min in group A, 8.5 min in group B) or median fluoroscopy time (5 s in group A, 4 s in group B). All children in group B showed signs of discomfort from the nose when given midazolam intranasally. In conclusion, this study indicates that intravenous administration of midazolam is preferable to the intranasal route.     

Treatment of Idiopathic Nephrotic Syndrome with Levamisole

Thirty children with frequently relapsing idiopathic nephrotic syndrome (INS) were treated with levamisole (2.5 mg/kg BW) twice a week for a mean period of 9.9 months. A beneficial effect was observed in 16 children in whom corticosteroids could be significantly decreased without relapse. Levamisole was ineffective in 14 patients. There was no difference between the two groups in the duration of INS, the number of relapses and the duration of treatment with levamisole. The mean age at onset of INS was higher in the group of patients where levamisole was effective (5.8 years versus 2.8 years). In 7 patients who responded to levamisole neutrophils decreased below 4×10⁹/l. Transient granulocytopenia was observed in 3. It is concluded that levamisole may be effective in frequently relapsing INS with minimal side effects     

The regulatory function of umbilical cord blood CD4+ CD25+ T cells stimulated with anti-CD3/anti-CD28 and exogenous interleukin (IL)-2 or IL-15

The abundance of CD4⁺ CD25⁺ regulatory T cells in umbilical cord blood (UCB) might contribute to the decreased severity of graft-vs.-host disease (GVHD) for UCB transplantation. This study aims to characterize the phenotypes and suppressive function of UCB CD4⁺ CD25⁺ T cells under the influence of anti-CD3/anti-CD28 (CD3/CD28) and exogenous interleukin (IL)-2 or IL-15. Higher percentages of CD4⁺ CD25^high and FoxP3⁺ cells were detected in UCB compared to their adult counterparts. IL-15 was as effective as IL-2 in enhancing the proliferation of CD3/CD28 stimulated UCB CD4⁺ CD25⁺ T cells. Phenotypically, IL-2/IL-15-stimulated UCB CD4⁺ CD25⁺ T cells expressed higher level of CTLA-4, GITR, membrane bound transforming growth factor-β (mTGF-β), and especially Foxp-3 than controls. IL-2/IL-15-stimulated UCB CD4⁺ CD25⁺ T cells also produced much higher IL-10 and TGF-β than controls; while IL-2/IL-15-stimulated UCB CD4⁺ CD25⁻ T cells showed increased TGF-β, but not IL-10 production. IL-2/IL-15-cultured UCB CD4⁺ CD25⁺ T cells showed comparable suppressor activity on allogeneic adult CD4⁺ T-cell proliferation compared to controls, partly through a contact-dependent fashion. Taken together, IL-2/IL-15-stimulated UCB CD4⁺ CD25⁺ T cells show distinct regulatory T-cell phenotypic and functional features, and may be applied for the alleviation of GVHD severity following UCB transplantation.     

Simplified Immunoglobulin Treatment of Idiopathic Thrombocytopenic Purpura

ABSTRACT. The recommended dose of intravenous IgG for idiopathic thrombocytopenic purpura has been 0.4 g/kg on 5 consecutive days. A simplified approach, giving a single infusion of 0.8–1.0 g/kg over 8 hours, has been tried in a series of 11 children with newly diagnosed disease. In 8 cases the infusion produced a prompt platelet response culminating at 128–502×10⁹/1 after 3–13 days, and 4 of these cases required no further treatment while 2 needed a booster infusion due to an early relapse and 2 followed a chronic course. In 3 cases platelet responses were poor in spite of supplementary doses to a total of 1.4–2.0 g/kg: 2 infants failed to achieve normal platelet counts and 1 case with fulminant bleeding manifestations proved completely resistant. Significant side effects were not observed. These results indicate that IgG-therapy practically may be initiated with a single infusion, the resulting platelet response indicating the need for further infusions.     

Case report of common variable immunodeficiency with functional T-helper defect and reduced CD4+ LAM−1 T cells

A 10 year-old boy presenting with an empyema and a previous medical history of recurrent and disseminated infections was investigated immunologically. The serum immunoelectrophoresis showed hypogammaglobulinaemia. The in vitro lymphocyte proliferation to T-cell mitogens (PHA and Con A) was diminished and the response to a T-dependent B cell mitogen (PWM) was severely diminished. Phenotypic analysis of his lymphocytes with monoclonal antibodies revealed normal CD3⁺, CD4⁺ and CD8⁺ cells with a normal CD4: CD8 ratio. Double immunofluorescence with Leu 8 antibody revealed a selective deficiency of the CD4⁺ LAM 1⁻ subset. Co-culture experiments between patient's B cells and supernatants from normal T cells showed that the patient's B cells could secrete Ig in vitro. We suggest that the Leu 8 monoclonal antibody may be useful in defining abnormalities in the regulatory subsets of T lymphocytes and that these abnormalities may be relevant in the pathogenesis of common variable immunodeficiency.     

Flow Cytometric Analysis for the Evaluation of the Rat Sperm Viability and Number in the Male Reproductive Toxicity Studies

Abstract We investigated the application of flow cytometric analysis to evaluate the rat sperm viability and number in the male reproductive toxicity studies. Flow cytometric procedure has been developed to evaluate sperm number and viability that uses fluorescent dye (propidium iodide, PI) to distinguish between viable (negative staining) and dead (positive staining) sperm. Sperm samples were collected from the caudal epididymides of SD rats (13–21 weeks old). PI staining patterns/viabilities were compared among several ranges of sperm concentrations, and several kinds of sperm viability. Viabilities determined by flow cytometry (FC) were also compared with motility by direct microscopical observation in several kinds of sperm viability. No notable changes in the PI staining patterns/viabilities were observed in the range from 1 × 10⁵ to 6 × 10⁶ sperm/ml. Essentially similar results were obtained from both FC and microscopical analyses for three degrees of viability sperm: live sperm (general preparation as a control), weakly viable sperm (mixed by vortex mixer for 30 seconds), and dead sperm (treated with 90°C or Triton X-100).
Viabilities of normal rat samples were 95.0 ± 4.0% in FC and 93.7 ± 4.6% in microscopical observation, indicating good correlation in both analyses. Sperm numbers with FC analysis were approximately 0.8 × 10⁶ to 1.8 × 10⁶ sperm per mg indicating good correlation with those by microscopy.
It was concluded that the present flow cytometric procedure was objective, rapid and reliable, and that it was one of the useful methods for measuring the number and evaluating the viability of sperm collected from the caudal epididymides of rats in the male reproductive toxicity studies.     

Screening for PTLD in lung and heart-lung transplant recipients by measuring EBV DNA load in bronchoalveolar lavage fluid using real time PCR

Abstract:  Pediatric L-HLTx recipients are at risk for developing PTLD with the lung being a primary site of disease. We hypothesized that BALF is a better sample than peripheral blood for measuring EBV DNA load in this high-risk population. Archived BALF specimens from pediatric L-HLTx recipients with and without PTLD were assayed for EBV DNA load using a quantitative real time TaqMan PCR assay. These values were compared with values determined in peripheral blood by a competitive PCR assay. Fifty-five BALF specimens from 16 L-HLTx patients were evaluated. Three patients with PTLD had mean BALF EBV DNA load values almost 50-fold higher than subjects without PTLD (4.6 × 10⁵ copies/mL vs. 1.0 × 10⁴ copies/mL). Patients who were EBV seronegative pretransplantation (i.e., high risk for PTLD) had elevated EBV DNA load values vs. patients who were EBV seropositive pretransplantation, regardless of the diagnosis of PTLD (mean values of 3.2 × 10⁵ copies/mL vs. 1.1 × 10⁴ copies/mL). Lastly, BALF analysis identified all subjects with PTLD, whereas peripheral blood analysis identified only one of these cases. Therefore, it can be concluded that monitoring EBV DNA load in BALF following L-HLTx facilitates detection of PTLD in high-risk patients and may be superior to peripheral blood assays.     

Acute Leukemia with Normal Platelet Count at Diagnosis

Thirty-six (17.8%) of 202 children with acute lymphoblastic leukemia (ALL) and 2 (3.7%) of 54 children with acute nonlymphoblastic leukemia (ANLL) had a platelet count over 150 times 10⁹/1 at diagnosis. Children with ALL and a platelet count over 150 times 10⁹/1 were analysed in detail. The ALL patients without thrombocytopenia tended to be male predominant and had less frequent bleeding manifestations (p < 0.01).These patients without thrombocytopenia had also significantly less marked leukocytosis (p < 0.01), less severe anemia (p < 0.05) and lower percentages of bone marrow blasts (p < 0.05) than those with thrombocytopenia. In addition, ALL patients without thrombocytopenia had a significantly higher probability of continuous complete remission than those with thrombocytopenia (p < 0.01).     

Leukocyte‐reduction to prevent transfusion‐transmitted cytomegalovirus infections

Abstract: Certain infectious organisms, including cytomegalovirus, are associated 'exclusively' with blood leukocytes (WBC), and their transmission by transfusion is strikingly diminished by marked WBC‐reduction of cellular blood components. Based on several reports of WBC‐reduction, it is clear that the risk of CMV is nearly eliminated by consistently removing WBC to a level < 1–5 × 10⁶ WBCs/unit (≤ 1 × 10⁶ preferred in Europe; ≤ 5 × 10⁶ in the United States). Alternatively, the rate of CMV infections is reduced by transfusing blood components collected from donors negative for CMV antibody. However, neither technique is perfect, with a failure rate of 1–4%. Although WBC‐reduction is favored by many experts, practitioners must choose the method that they believe to be most efficacious – being mindful that data do not exist to establish additive protection by combining WBC‐reduction and transfusion of blood components collected from antibody negative donors.