Late onset subgaleal hemorrhage infection with <Emphasis Type=Italic>Streptococcus pneumoniae</Emphasis>?

We report a case of an infected subgaleal hematoma caused by an unusual micro-organism in a previously healthy 11-month-old girl. Our patient presented at the emergency department with an increasing scalp swelling for 2 weeks, and culture of the evacuated fluid yielded Streptococcus pneumoniae. Although she was born after vacuum delivery and a scalp swelling was noticed from the third day of life, this swelling disappeared completely at the age of 3 months. Parents were thoroughly questioned but we could not find out a new traumatic head event. We postulate that in our patient, a subgaleal hemorrhage developed after vacuum delivery and possibly infected 11 months later, presumably from hematogenous seeding of an acute otitis media. The patient recovered well after surgical drainage and antimicrobial therapy.     

Inflammatory myofibroblastic tumor of the liver due to <Emphasis Type=Italic>Μycobacterium tuberculosis</Emphasis> in an immunocompetent girl

The case of a 9-year-old girl with a Mycobacterium tuberculosis inflammatory myofibroblastic tumor (IMT) of the left lobe of the liver is reported. The tumor was surgically excised and had histological features diagnostic of IMT, a positive Ziehl-Nielsen staining for acid-fast bacilli and a positive polymerase chain reaction for Mycobacterium tuberculosis. Surgical excision of the tumor followed by anti-tuberculosis treatment for 9 months resulted in full recovery. The patient had no apparent immune disorder, and there was no evidence of extrahepatic tuberculosis. These findings make this case exceptional because IMTs, due mostly to atypical mycobacteria, have been described only in immunocompromised patients.     

Effect of albumin administration prior to exchange transfusion in term neonates with hyperbilirubinemia — <Emphasis Type=Italic>A randomized controlled trial</Emphasis>

Objective  

To determine the role of intravenous administration of human albumin prior to blood exchange in term neonates for reduction of total serum bilirubin (TSB).     

Novel <Emphasis Type="Italic">UBR1</Emphasis> gene mutation in a patient with typical phenotype of Johanson–Blizzard syndrome

Johanson–Blizzard syndrome is a rare autosomal recessive disorder, characterized by exocrine pancreatic deficiency and a wide range of other abnormalities. We present here an infant with failure to thrive, exocrine pancreatic deficiency, short stature and developmental delay, cutis aplasia on the scalp, aplasia of alae nasi, hypospadias, hypothyroidism, myxomatous mitral valve, and patent ductus arteriosus. Molecular studies revealed a novel homozygous nonsense mutation in exon 38 of the UBR1 gene, which confirmed the diagnosis of Johanson–Blizzard syndrome. It should be acknowledged that the combination of exocrine pancreatic insufficiency and nasal wing hypo-aplasia is pathognomonic for this syndrome. Prompt diagnosis and exact monitoring of the patients with JBS are required to avoid further complications.     

Hematopoietic stem cell transplantation for children with <Emphasis Type="Italic">β</Emphasis>-thalassemia major: multicenter experience in China

Background

β-Thalassemia major (β-TM) has become a public health problem in mainland China. Hematopoietic stem cell transplantation (HSCT) has remained the only cure for β-TM in mainland China since 1998.

Methods

This multicenter retrospective study provides a comprehensive review of the outcomes of 50 pediatric patients with β-TM who received HSCT between 1998 and 2009 at five centers in mainland China. Both related (n = 35) and unrelated donors (n = 15) with complete human leukocyte antigen matches were included. The stem cell sources included bone marrow (BM), peripheral blood stem cells, umbilical cord blood (UCB) and a combination of BM and UCB or a combination of BM and peripheral blood stem cells from a single sibling donor.

Results

The probabilities of 5-year overall survival (OS) and thalassemia-free survival (TFS) after the first HSCT were 83.1 and 67.3%, respectively. Graft failure (GF) occurred in 17 patients. Univariate analyses showed that umbilical cord blood transplantation (UCBT) was one of the potential risk factors for decreased OS (P = 0.051), and that UCBT (P = 0.002) was potentially related to TFS. GF incidence was distinct between the UCBT and non-UCBT groups (P = 0.004). Four cases of UCB-BM combined transplantation led to decreased risks of mortality and recurrence. In the UCBT group, related donor transplantation produced more favorable results than unrelated donor transplantation in OS (P = 0.009) but not in TFS (P = 0.217).

Conclusions

GF was the primary cause of UCBT failure. Though UCBT from related donors was not favorable, the combined transplantation of UCB and BM could improve the prognosis of UCBT.

     

Broad and unexpected phenotypic expression in Greek children with steroid-resistant nephrotic syndrome due to mutations in the Wilms’ tumor 1 (<Emphasis Type="Italic">WT1</Emphasis>) gene

Mutations in the Wilms’ tumor suppressor gene 1 (WT1), most commonly within exons 8 or 9 or intron 9, are found in cases with the overlapping conditions of Denys–Drash and Frasier syndromes, as well as in patients with steroid-resistant nephrotic syndrome (SRNS). This study investigated the presence of WT1 gene mutations in cases with childhood SRNS, along with an evaluation of their clinical outcome. Twenty-seven Greek children with sporadic (19 cases) and familial (8 cases) SRNS were tested. Four phenotypically female patients with sporadic SRNS were found to carry de novo WT1 mutations, including two cases with p.R394W, and one case each with p.R366H, or n.1228+5G>A. Karyotype analysis found 46XX in three cases, but 46XY in one. No phenotype–genotype correlations were apparent in the WT1 gene positive cases since their clinical presentation varied broadly. Interestingly, one patient with a pathological WT1 nucleotide variation responded fully to combined therapy with cyclosporine A and corticosteroids. This study further illustrates that investigation of WT1 gene mutations is clinically useful to support definitive diagnosis in children presenting with SRNS in order to direct the most appropriate clinical management.     

Measuring the Prevalence of Children at Risk Using <Emphasis Type=Italic>Parents’ Evaluation of Developmental Status</Emphasis> in a Telephone Survey

This study determined the reliability and feasibility of adding a validated parent-report screening tool to a public health telephone survey to estimate the prevalence of children at risk for developmental problems. Adults with children (0 to 6 years) in three public health regions in Ontario, Canada, were surveyed by telephone using the Parents’ Evaluation of Developmental Status (PEDS) tool; a 10-item screening measure that involves eliciting, categorizing and weighing parents’ concerns about their children. In Phase 1, responses to the PEDS were taped and reviewed by an expert in the PEDS and child development. Lay telephone interviewers’ and the expert’s PEDS scores were compared. In Phase 2, participants were mailed the PEDS for written completion; written scores were compared to telephone interview scores. Reliability was assessed by agreement and Kappa statistics. In Phase 1, overall agreement was 0.83, with weighted kappas = 0.74–0.78, indicating good-to-excellent agreement between scores generated from trained lay interviewers and those from the expert. In Phase 2, overall agreement was 0.69, with weighted kappas = 0.59–0.62, representing fair-to-good agreement between telephone and written modes of administration. Telephone administration of PEDS tended to identify lower risk levels than written administration. The average time spent collecting information over the telephone was less than two minutes. The PEDS can feasibly and reliably be added to a telephone-based health surveillance system to assess the prevalence of children at risk for developmental problems. Training requirements for lay interviewers were acceptable and they were able to code developmental information with a high degree of reliability.     

<Emphasis Type=Italic>PTPN11</Emphasis> Gene Mutation and Severe Neonatal Hypertrophic Cardiomyopathy: What Is the Link?

Noonan syndrome (NS) is an autosomal dominant disorder characterized by multiple dysmorphic features and a broad spectrum of congenital heart defects. Specific mutations of the PTPN11 gene are associated with 50% of the NS cases and 90% of the multiple lentigines/LEOPARD syndrome (ML/LS) cases. These two allelic conditions have several overlapping clinical features. This study describes the association between the Gln510Glu mutation of the PTPN11 gene and lethal progressive hypertrophic cardiomyopathy (HCM) in a newborn with the NS phenotype. The findings confirm the intriguing relationship between site-specific mutations of the PTPN11 gene and rapidly progressive HCM.     

Interaction of Hb South Florida (codon 1; <Emphasis Type=Underline>G</Emphasis>TG→<Emphasis Type=Underline>A</Emphasis>TG) and HbE,with β-thalassemia (IVS1-1; G→A): expression of different clinical phenotypes

Introduction  Interactions of different hemoglobin variants with thalassemia alleles can result in various clinical phenotypes. HbE-β-thalassemia generally manifests with severe anemia where individuals exhibit β-thalassemia major with regular blood transfusions or β-thalassemia intermedia with periodic blood transfusions. This study presents a unique Malay family with three β-globin gene defects—HbE, Hb South Florida, and IVS1-1 (G→A). Materials and methods  HbE activates a cryptic splice site that produces non-functional mRNAs. Hb South Florida is a rare β-hemoglobin variant, and its interactions with other β-thalassemia alleles have not been reported. IVS1-1 is a Mediterranean mutation that affects mRNA processing giving rise to β^o-thalassemia. Results and discussion  Fifteen mutations along the β-globin gene complex were analyzed using the amplification refractory mutation system. Hb South Florida was identified by direct sequencing using genomic DNA Conclusion  The affected child with HbE/IVS1-1 produced a β-thalassemia major phenotype. Compound heterozygosity for Hb South Florida/IVS1-1 produced a β-thalassemia carrier phenotype in the mother.     

A novel <Emphasis Type="BoldItalic">WT1</Emphasis> gene mutation in a patient with Wilms’ tumor and 46, XY gonadal dysgenesis

Denys–Drash syndrome (DDS) is a rare genetic disorder featuring the triad of Wilms' tumor, early-onset renal failure, and 46, XY disorder of sex development. DDS is usually caused by heterozygous missense mutations in the zinc-finger region of the WT1 gene. The most frequent constitutional WT1 mutations in DDS patients are missense mutations in exons 8 and 9. We present a new case of variable DDS in a child who was found to have a novel heterozygous missense mutation in exon 7 (c.905G>T) and a splicing mutation in exon 6 (IVS6-1G>T).     

Tetracycline-resistant <Emphasis Type=Italic>Escherichia coli</Emphasis> strains are inherited from parents and persist in the infant’s intestines in the absence of selective pressure

The study investigated tetracycline (TC), ampicillin (AMP), cefazolin (CEF), and trimethoprim (TMP) resistance in Escherichia coli (E. coli) in the feces of 21 infants up to 6 months of age and in their parents in the absence of selective antimicrobial pressure. Clonality of strains was assessed by pulsed-field gel electrophoresis. Three infants had resistant E. coli strains in their feces identical to the mothers’ from week 1 on, which persisted over weeks. From week 2 on, in another four infants, persisting resistant E. coli were found, two of them identical to the mothers’. All of these persisting E. coli strains (except one family) showed at least resistance to TC. In infants, resistant E. coli strains inherited from their mothers tended to persist over months. Therefore, the persistence of resistant E. coli and their possible capacity to cause symptomatic infection or transfer its resistance genes to other bacteria deserves more attention. Martina Prelog and Katharina Grif contributed equally to this work.     

Severe combined immunodeficiency caused by a splicing abnormality of the <Emphasis Type="Italic"> CD3δ </Emphasis>gene

CD3 deficiency is a recently identified rare form of severe combined immunodeficiency. We analysed the CD3 gene in a Japanese family with severe combined immunodeficiency. The patients lacked T-cells with normal numbers of B-cells and natural killer cells in peripheral blood. We found a novel homozygous mutation in the splicing acceptor site of intron 2 (IVS2–2AG) in these patients. Analysis of patients mononuclear cells revealed the CD3 splicing abnormality. Chest X-ray films and computed tomography revealed small sized thymuses in these patients. Conclusion:The CD3 gene should be analysed in patients with severe combined immunodeficiency lacking T-cells with normal B- and natural killer cells irrespective of the thymus size.     

A novel <Emphasis Type="Italic">SOX10</Emphasis> mutation in a patient with PCWH who developed hypoxic–ischemic encephalopathy after <Emphasis Type="Italic">E. coli</Emphasis> sepsis

We describe a male infant with a novel SOX10 mutation and a severe course of PCWH—a special phenotype of Shah-Waardenburg syndrome involving peripheral demyelinating neuropathy, central dysmyelinating leukodystrophy, Waardenburg syndrome, and Hirschsprung’s disease. The patient had severe hypoplastic hypoganglionosis of the small and total colonic intestine together with peripheral and central dysmyelination. The patient was completely dependent on parenteral nutrition. We identified a novel frameshift mutation, p.Asp293GlyfsX10, in the SOX10 gene of this patient. The mutation would encode a protein that lacked the transactivation domain and resulted in the largest duplication described to date. At the age of 20 months, the boy presented with a severe complication with a translocation of Escherichia coli and developed sepsis leading to severe hypoxic–ischemic encephalopathy with persistent vegetative state (PVS). The boy died at the age of 24 months. Conclusion: Septic encephalopathy with hypoxic–ischemic encephalopathy can be a serious complication in severe sepsis. It is unknown to what extent the mutant SOX10 protein influenced the degree of brain injury—for example central nervous system susceptibility to hypoxia—during sepsis, which may explain the severe encephalopathy with clinical signs of PVS the boy developed.     

Studies of <Emphasis Type="Italic">RET</Emphasis> gene expression and acetylcholinesterase activity in a series of sporadic Hirschsprung’s disease

The purpose is to present the studies of RET gene expression and acetylcholinesterase activity in 23 patients operated for Hirschsprung's disease (HD). The patients underwent either transanal endorectal pull-through or Duhamell's procedure. Full-thickness intestinal samples from the three different segments (ganglionic, intermediate and aganglionic) were collected. Each tissue sample was divided in two portions, one for AChE histochemical staining and the other for examination of RET mRNA expression level. All patients had an uneventful postoperative recovery. In all patients, the AChE stainings demonstrated the absence of activity in the ganglionic area, the marked increase of positive fibers in the aganglionic area, and little increase of positive fibers in the intermediate area. In the ganglionic and intermediate areas, all patients (100%) showed significant RET gene expression. In the aganglionic area, 18 patients (78.3%) did not present gene expression and the other five patients (21.7%) presented gene expression that was similar to the ganglionic and intermediate areas. The results reinforce the conclusion that the method of AChE staining is effective for the diagnosis of intestinal aganglionosis and confirm the knowledge that genes beyond RET may be implicated in the genesis of sporadic cases of HD.     

The use of Surgisis<Superscript><Emphasis Type="Bold">®</Emphasis></Superscript> for abdominal wall reconstruction in the separation of omphalopagus conjoined twins

Abdominal wall reconstruction in omphalopagus twins poses a difficult reconstructive challenge, as separation often results in a large abdominal wall defect. A number of options are available for closure, including tissue flaps, expanders and patches made of foreign material. Surgisis is a new biodegradable small intestine scaffolding substrate that permits tissue in-growth and results in a permanent durable scar. We describe its use in abdominal wall reconstruction after separation of a set of conjoined twins. A set of omphalopagus conjoined twins shared liver and abdominal wall. After separation at 6 months of age, Twin A's abdomen could be closed primarily, but Twin B could not. A 4-ply Surgisis mesh was used in the upper abdominal closure, and a skin flap was created, to completely cover the patch. Both twins survived the operation. A small portion of the skin flap over the Surgisis broke down, healing by secondary intention. In follow up of over 18 months post procedure, there have been no wound infections and the abdominal wall is intact with no evidence of a hernia. Surgisis can be successfully used for the reconstruction of complex abdominal wall defects in the pediatric patient, including reconstruction after separation of conjoined twins.     

Identification of two novel mutations in the <Emphasis Type="Italic">ATP7B</Emphasis> gene that cause Wilson’s disease

Background:Wilson's disease is an autosomal recessive disorder characterized by liver disease and/or neurologic deficits due to copper accumulation and is caused by pathogenic mutations in the ATP7B gene.Methods:Two unrelated Chinese patients born to nonconsanguineous parents who were diagnosed with earlyonset Wiison's disease.DNA sequencing and bioinformation analysis were conducted.Results:We have identified four mutations in two family trios,of which two were novel,namely,c.3028A＞G(p.K1010E) and c3992T＞G (p.Y1331X),in each patient.Conclusions:Gene testing is playing an important role in diagnosis of Wilson's disease.The early-onset of Wilson's disease is apparently not associated with P-ATPase domain in the ATP7B protein.Our findings further widen the spectrum of mutations involving the ATP7B gene.