Juvenile neuronal ceroid lipofuscinosis

A case of juvenile neuronal ceroid lipofuscinosis (JNCL) diagnosed on the basis of clinical features, electrophysiologic studies and skin electron microscopy is reported. JNCL was suspected on the basis of characteristic symptoms including progressive loss of vision, seizures, mental retardation and motor disabilities. Diagnosis was confirmed by neurophysiological and biopsy studies. The disease is caused by 23 different mutations in a gene recently isolated on chromosome 16p11.2-12.1. Although universally fatal, characterisation of mutations can help in prenatal diagnosis in future pregnancies.     

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??Objective??To investigate diagnosis of children’s neuronal ceroid lipofuscinosis??NCL????especially the significance of gene diagnosis. Methods??The clinical data of 5 cases of suspected NCL in our hospital from January 2013 to January 2017 were retrospectively analyzed. There were 3 boys and 2 girls??2 of whom were sister and brother. The age of onset ranged from 3 years and 4 months to 8 years and 1 month?? averaged 5 years and 9 months. The first visit to our hospital ranged from 3 years and 6 months to 14 years?? with an average of 8 years and 1 month. DNA of peripheral blood was extracted from 4 children with abnormal imaging and their parents and brothers??and the related genes were detected. Results??Four cases of children were diagnosed with NCL??and 1 case was diagnosed with hysteria??gene detection showed??case 1?? TPP1 gene c.887-17A??G was a shearing variant??and c.646G??A was a missense mutation??case 2?? TPP1 gene c.1015_1016 del was frameshift mutation??and c.640C??T was nonsense mutation??the nucleotide of case 3?? CLN6 gene changed to c.158T??C??p.L53P?? and c.889C??T??p.P297S??. The parents of the 3 cases only carried one of the heterozygous variants??and the brother of case 3 had no mutation. Heterozygous mutation existed in case 4?? CLN3 gene??c.1160_1169 delCAGCCTACGTinsGC??which was not detected in the mother??and there was the deletion of the paternal sample??there was loss of heterozygosity in the exon E3-E8 of the CLN3 gene??which was the true missing from mother. Five cases were followed up for 15-60 months and there was no death. Conclusion??Suspected NCL patients should be checked head MRI??electroencephalogram and gene. The gene mutation leads to NCL??such as TPP1??c.887-17A??G??c.1015_1016 del????CLN3??c.1160_1169 delCAGCCTACGTinsGC????CLN6???c.158T??C??p.L53P?? and c.889C??T??p.P297S?????are reported for the first time. Genotype is very important for NCL classification and prognosis.     

皮肤活检诊断青少年型神经元腊样质脂褐素沉积病

目的　通过皮肤活检诊断青少年型神经元腊样质脂褐素沉积病 (青少年型NCL) ,探讨指纹体样脂褐素在非神经元细胞内的表现。方法　根据 1例患儿的病史、症状、体征和辅助检查 (头颅CT、核磁共振成像、脑电图 )结果 ,结合患儿左上臂皮肤和肌肉活检标本的光镜和电镜检查结果确定诊断。结果　患儿 ,9岁 6个月 ,进行性视力减退、癫和痴呆 3年半。家族中无类似发病者。发病后 2年半MRI显示弥漫性脑萎缩 ,侧脑室旁白质在T2 像信号略增高。脑电图显示阵发性全导慢波爆发和额枕区为主的棘慢波。皮肤和肌肉的光镜检查无明显异常。电镜下小汗腺分泌部的上皮细胞内出现指纹体样脂褐素 ,指纹体样脂褐素具有三种表现形式 :(1)指纹体 曲线体 膜性空泡结构 ;(2 )非空泡化指纹体 ;(3)膜性包裹的颗粒基质中间的指纹体结构。在皮肤和肌肉的其他细胞内没有发现典型指纹体结构。结论　典型临床表现和全脑萎缩的影像学特点提示可能存在NCL ,通过皮肤活检可以确诊青少年型NCL。指纹体脂褐素存在多种表现形式 ,可以选择性出现在小汗腺分泌部的上皮细胞内 ,而不出现在皮肤非汗腺组织。     

神经元蜡样脂褐质沉积症3例临床及基因变异分析

目的探讨神经元蜡样脂褐质沉积症(NCL)的临床和基因变异特征。方法回顾分析3例NCL患儿的临床资料和基因检测结果。结果 3例女性患儿,多表现为认知和运动倒退、不同程度的癫痫发作、视力受累。全外显子测序发现,例1的PPT1基因存在c.124+1GA及c.413CT复合杂合变异,其中c.124+1GA遗传自父亲,c.413CT遗传自母亲;例2及其哥哥PPT1基因存在c.181CT及c.536+1GA复合杂合变异,其中c.181CT遗传自父亲,c.536+1GA遗传自母亲;例3的CLN8基因存在c.768GT及c.209GT复合杂合变异,其中c.768GT遗传自父亲,c.209GT遗传自母亲。c.768GT和c.209GT是既往未见报道的新的变异位点。结论基因检测有助NCL的诊断及遗传咨询;PPT1基因变异可呈现不同的临床表现,即使是同一家系具有相同变异位点的个体临床表现也各不相同。     

Comparable outcomes of HLA-matched unrelated and HLA-identical sibling donor bone marrow transplantation for childhood acute myeloid leukemia in first remission

Abstract:  We retrospectively investigated the outcomes of HLA-matched unrelated BMT (MU-BMT, n = 13) and HLA-identical sibling donor BMT (MS-BMT, n = 17) for childhood AML in CR1 between June 2002 and August 2005. Engraftment of neutrophil and platelet did not differ between the two transplant groups. The cumulative incidence of grade II–IV acute GVHD and any chronic GVHD at three yr was not different between MS-BMT and MU-BMT. Of the 30 patients, four patients experienced relapses (three with MS-BMT, one with MU-BMT) and four patients died of transplant-related complications (two with MS-BMT, two with MU-BMT). A total of 23 patients survived with a median follow-up of 43.2 months. The Kaplan–Meier estimates for EFS rates at three yr were 71% and 77% for MS-BMT and MU-BMT, respectively, and the OS rates were 76% and 77% for MS-BMT and MU-BMT, respectively. The outcome of HLA-matched unrelated BMT is comparable to that of HLA-identical sibling BMT for childhood AML in CR1. HLA-matched unrelated BMT may be recommended for patients who have AML in CR1 without an HLA-matched sibling donor.     

Factors associated with bone marrow stem cell yield for pediatric allogeneic stem cell transplantation: The impact of donor characteristics

The aim of this study was to investigate the effects of donor characteristics on CD34⁺ cell yield in BM harvest. Between April 2010 and November 2013, consecutive donors who underwent BM harvesting in our BM transplantation unit were retrospectively investigated. Donors were classified into two groups: those who donated BM without mobilization (steady‐state BM donors) and those who received G‐CSF for stem cell mobilization (G‐CSF‐primed BM donors). Donor characteristics (age, gender, race, body weight, BMI, and laboratory factors including donor's leukocyte, platelet, and monocyte) and their relationship with total nuclear cell and CD34⁺ cell numbers has been evaluated. A total of 64 healthy related donors (29 males/35 females, median age 11.2 years; 49 [76.6%] younger than 18 and 36 [56.3%] younger than 12 years) were included in the study. The median CD34⁺ cell yield in the harvest was 0.12×10⁶/L (0.02‐0.21) in SS‐BM donors and 0.18×10⁶/L (0.09‐0.67) in GP‐BM donors (P=.03). Median of CD34⁺ cell count given to recipients was 2.6×10⁶/recipient body weight (1.3‐19.3) in SS‐BM yields and 3.8×10⁶/recipient body weight (1.1‐10.2) in GP‐BM yields, respectively. Multiple regression analysis showed that donor height and pre‐G‐CSF platelet were the most important parameters to obtain a sufficient BM harvest. Our data suggest that the shorter donors and the donors with higher thrombocyte counts may offer more hematopoietic stem cell. The height and thrombocyte count of the donors should be taken into consideration before planning the targeted CD34⁺ cell count especially for pediatric donors.     

Secondary neuroendocrine tumor after allogeneic bone marrow transplantation

Here we report a case of aggressive neuroendocrine tumor (NET), which is an extremely rare secondary solid tumor that occurs after allogeneic hematopoietic cell transplantation (allo‐HSCT). A patient with chronic active Epstein–Barr virus infection received allo‐HSCT from an HLA‐DR two allele‐mismatched unrelated donor. Four years later, he developed NET with multiple metastases. He received thoraco‐abdominal irradiation as a conditioning regimen, and developed repeated episodes of intestinal graft‐versus‐host disease, for which he received long‐term immunosuppressive therapy. Although these factors may be potential contributing factors to the development of secondary NET, the exact pathogenesis remains unclear.     

Successful unrelated bone marrow transplantation in two siblings with alpha-mannosidosis

Yesilipek AM, Akcan M, Karasu G, Uygun V, Kupesiz A, Hazar V. Successful unrelated bone marrow transplantation in two siblings with alpha-mannosidosis. Abstract: Alpha-mannosidosis is a rare lysosomal storage disorder with an autosomal recessive inheritance. Deficient alpha-mannosidase activity leads to lysosomal accumulation of mannose-rich oligosaccharides. The disease characterized by mental retardation, skeletal changes, hearing impairment, and recurrent infections. Stem cell transplantation has been shown to be an effective treatment. It works by providing increased levels of α-mannosidase in the localized extracellular milieu to provide improvements in skeletal malformations, neurocognitive, and sensorineural function. In this case report, we describe a pair of siblings with α-mannosidosis who successfully underwent HSCT from matched unrelated donors. In both siblings, enzyme levels reached to normal limits and improvements in clinical symptoms were recognized early after HSCT. We conclude that HSCT should be considered as a therapeutic approach in patients with alpha-mannosidosis before disease-related complications have developed.     

Haploidentical bone marrow transplantation in Mexico

Haploidentical hematopoietic cell transplantation using CD34⁺ cells depleted of T lymphocytes by the CliniMACS is a treatment for hematological malignancy. We report on four Mexican children, three with acute lymphocytic leukemia and one with chronic myelocytic leukemia, who was transplanted with 12 × 10⁶ CD34⁺ stem cells/kg body weight (98% of purity) with a follow‐up of years. The engraftment was successful in three of the four children. All showed cytomegalovirus reactivation, and one died because of graft rejection and infectious complication. The risk of infections was a major problem. Pediatr Blood Cancer 2012; 59: 950–952. © 2012 Wiley Periodicals, Inc.     

异基因造血干细胞移植治疗粘多糖病I型1例报告

目的：粘多糖病I型是一种进行性多器官受累的遗传代谢性疾病,Hurler综合征是粘多糖病I型的最严重类型,常导致进行性的中枢神经系统受损和早期死亡。该研究进行了异基因造血干细胞移植治疗该病的初步尝试,探讨异基因干细胞移植治疗粘多糖病的疗效。方法：1例男性粘多糖病I型Hurler综合征患者,2岁1个月,供者为其胞姐,HLA配型一个HLA-B位点不合。预处理方案为减低预处理剂量的BuCy方案马利兰(BU)每日3.7mg/kg,-9~-6d;环磷酰胺(Cy)每日42.8mg/kg,-5~-2d;抗胸腺细胞球蛋白每日3.5mg/kg,-7,-5,-3,-1d。输入重组人粒细胞集落刺激因子动员的供者CD34+细胞(12.8×106/kg),以环孢素A、骁悉、赛呢哌、抗胸腺细胞球蛋白和氨甲喋呤预防移植物抗宿主病(GVHD)。结果：移植后14d,短串联重复序列结合聚合酶链反应(STR-PCR)检测显示为完全供者型嵌合,中性粒细胞和血小板植活时间分别为+11d和+19d。仅出现肝、胃肠Ⅰ级预处理相关毒性,无严重预处理相关并发症。未发生急、慢性移植物抗宿主病和移植物衰竭,移植后临床症状明显改善,认知能力持续增加。结论：异基因造血干细胞移植治疗粘多糖病I型疗效肯定,减低剂量的预处理方案有利于降低预处理相关毒性;移植前后加强免疫抑制治疗,适当增加供者造血干细胞输注数量,有利于促进植入,减少移植物衰竭以及GVHD的发生。     

异基因造血干细胞移植治疗噬血细胞综合征

噬血细胞综合征又称噬血细胞性淋巴组织细胞增生症,分为原发性和继发性两大类.对于家族性噬血细胞综合征(familial hemophagocytic lymphohistiocytosis,FHL)和难治性EB病毒相关噬血细胞综合征(EBV-HLH),异基因造血干细胞移植是目前唯一有效的治疗手段,但其鉴别诊断尤为困难,移植后多种并发症以及高病死率也受到越来越多人的关注.该文总结了近年来异基因造血干细胞移植治疗FHL和难治性EBV-HLH在诊断、预处理方案、移植后并发症、死亡原因分析及预后等方面的研究进展.     

造血干细胞移植治疗儿童白血病若干问题

该文涉及各类儿童造血干细胞移植(HSCT),如骨髓移植(BMT)、外周血造血干细胞移植(PBSCT)和脐血移植(UCBT)治疗白血病的优缺点及HSCT在儿童白血病治疗中的地位。绝大多数儿童白血病可通过正规联合化疗根治,仅少数(约20%)高危、难治及复发的白血病是异基因HSCT的适应证,无适合的同胞供体时,可选择HLA全相合非血缘相关BMT或PBSCT,UD-UCBT更适合于儿童患者。     

Successful hematopoietic cell transplantation following cardiac transplantation in two pediatric patients

We report two patients who underwent cardiac transplantation at a young age and subsequently required a HCT for varied indications. Despite the challenges associated with HCT following cardiac transplant, including need for altered immunosuppression, toxicities related to chemotherapy exposure, and infection risks, both patients are currently alive and well. There is a paucity of such successful cases documented in the literature, and these cases highlight the critical importance of an experienced, multidisciplinary team when caring for this patient population.     

Epstein-Barr virus-associated post-transplant lymphoproliferative disease after bone marrow transplantation mimicking graft-versus-host disease

In contrast to solid organ transplantation (Tx), the incidence of post-transplant lymphoproliferative disease (PTLD) after hematopoietic stem cell Tx (HSCT) is generally low. This risk, however, is significantly elevated in patients receiving human leukocyte antigen (HLA) mis-matched or T-cell-depleted grafts, or after treatment for severe graft-versus-host disease (GvHD). An 18-yr-old patient with positive Epstein-Barr virus (EBV) serology received a fully matched, unmanipulated bone marrow graft from an unrelated EBV-positive donor for treatment of acute myeloid leukemia (AML) in second complete remission. GvHD prophylaxis was performed with cyclosporin A (CsA) and a short course of methotrexate. Four months after Tx, the patient developed ulcerative tonsillitis that was unresponsive to antibiotic treatment. Diarrhea appearing simultaneously was interpreted as gastrointestinal GvHD and steroids were added to CsA. A few days later the patient was admitted to hospital because of generalized seizure and pneumonia. Despite reduction of immunosuppression, intensification of anti-viral treatment, and subsequent mechanical ventilation, the patient died of acute respiratory distress 6 days later. Autopsy demonstrated disseminated EBV-induced, multi-nodular lymphoma infiltration of the entire colon but no signs of GvHD. Moreover, both lungs, paratracheal lymph nodes, kidneys, thyroid gland, and liver were infiltrated with large B-cell non-Hodgkin's lymphomas. This case underlines the rapid and aggressive course of EBV-induced disseminated PTLD after HSCT, initially mimicking intestinal GvHD because of massive colonic lymphoma infiltration. Tissue biopsies should be performed early for establishing correct diagnosis, thus enabling specific therapy, e.g. infusion of donor leukocytes with cytotoxic T-lymphocytes.     

Allogeneic hematopoietic stem cell transplantation for infants with idiopathic myelofibrosis

IMF is a rare disease in children that can present during infancy and has a protracted course. The only known curative approach for this disease in adult patients is allogeneic HSCT. There are very few reports describing the long‐term outcome of young children following stem cell transplantation for IMF. We report on eight patients less than two yr of age with IMF that did not resolve with supportive care measures. All patients underwent myeloablative conditioning regimen with busulfan and cyclophosphamide ± ATG followed by HSCT from matched related (n = 6) or unrelated donor (n = 2). All patients achieved neutrophil and platelet engraftment. Four patients had grade II‐III acute GVHD, and chronic GVHD developed in five patients (three mild and two severe). At a median follow‐up of eight and a half yr (0.7–9), all patients are alive with complete resolution of their hematologic manifestations. At the last follow‐up, all patients had normal endocrine function except for one patient who developed hypothyroidism. To date, this is the largest cohort of young children with IMF treated successfully with HSCT, with the longest duration of follow‐up. In conclusion, our study showed that HSCT is a curative option for infants with IMF.     

Multiple extramedullary relapses without bone marrow involvement after second allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia

EMR without BM involvement after allogeneic HSCT is extremely rare, especially in children; only a few cases have been reported. A two-yr-old boy was diagnosed with AML (M4) and underwent allogeneic HSCT in first complete remission with BM from HLA-matched unrelated donor without GVHD. Four yr later, he had a BM relapse and after induction and consolidation chemotherapy, he received a second HSCT from an unrelated donor using peripheral blood stem cells. His second post-transplant course was complicated by extensive chronic GVHD involving the skin, oral cavity, and lungs, which was treated with tacrolimus and corticosteroid. Two yr later, he noticed a mild swelling in the right cheek area. The BM showed a complete remission marrow and a soft tissue biopsy was compatible with granulocytic sarcoma. PET-CT showed multifocal bone involvements. He received chemotherapy, and the chloromas decreased in size. We report a case of diffuse EMR of AML without BM involvement after a second allogeneic HSCT.     

Successful cord blood transplantation using a reduced‐intensity conditioning regimen for advanced childhood‐onset cerebral adrenoleukodystrophy

Awaya T, Kato T, Niwa A, Hiramatsu H, Umeda K, Watanabe K‐i, Shibata M, Yamanaka Y, Maruya E, Saji H, Nakahata T, Adachi S. Successful cord blood transplantation using a reduced‐intensity conditioning regimen for advanced childhood‐onset cerebral adrenoleukodystrophy.
Pediatr Transplantation 2011: 15: E116–E120. © 2009 John Wiley & Sons A/S. Abstract: The CCALD, which is caused by a mutation of the ABCD1 gene that encodes a peroxisomal membrane protein, progresses to a stage where the patient is in a vegetative state and can cause death within 3–5 yr after the appearance of neurological symptoms. Although HSCT is the only means of preventing the progression of this disease, HSCT is currently recommended only for cases diagnosed in the early stages. Previous reports on HSCT in advanced CCALD have indicated that the complications of the HSCT procedure seem to outweigh its benefits with respect to survival and neurological outcome. In this case, we successfully treated advanced CCALD with CBT using a reduced‐intensity conditioning regimen to reduce regimen‐related toxicity and transplant‐associated morbidity and mortality. Neither neurological deterioration nor deterioration of MRI abnormalities were observed during the clinical course. We report that CBT using the reduced‐intensity conditioning regimen was well tolerated, stopped disease progression and contributed to a good neuropsychological outcome in this case of advanced CCALD.