Aysenur Bahadir

The Treatment of Crimean-Congo Hemorrhagic Fever With High-dose Methylprednisolone, Intravenous Immunoglobulin, and Fresh Frozen Plasma

Crimean-Congo hemorrhagic fever (CCHF) is an acute tick-borne disease caused by Nairovirus, and it is sometimes characterized by reactive hemophagocytic histiocytosis (HLH). The reasons for reactive HLH are macrophage-activating syndrome and disseminated intravascular coagulation due to cytokine storm, liver dysfunction, and endothelial damage by the virus. In this study, the effectiveness of high-dose methylprednisolone (HDMP) (5 to 30 mg/kg/d), fresh frozen plasma (FFP), and intravenous immunoglobulin (IVIG) was investigated in patients with CCHF associated with reactive HLH. Twelve patients with CCHF in association with reactive HLH were included in the study. The patients were successfully treated with HDMP to suppress the macrophage activation, FFP to treat disseminated intravascular coagulation, and IVIG to treat severe thrombocytopenia. No patients received ribavirin. Fever reduced in 1.6±0.8 days, WBC count increased above 4.500/µL in 4.0±2.4 days, platelet count increased above 150.000/µL in 8.5±2.5 days, and D-dimer level decreased under 1 mcg/dL in 5.8±3.6 days. Consequently, HDMP, FFP, and IVIG may be effective in patients with CCHF associated with reactive HLH during hemorrhagic period of the disease.

Effects of adenoidectomy in children with symptoms of adenoidal hypertrophy

The purpose of this study was to compare the preoperative symptoms of children who had adenoid hypertrophy with postadenoidectomy symptoms. Sixty children undergoing adenoidectomy were included in this prospective uncontrolled study at the Farabi Hospital of Karadeniz Technical University, an academic tertiary medical center. The symptoms of each child were described by their parents. Adenoidectomy with myringotomy alone or with tympanostomy tube placement was performed in all children. Two months after the operation, the children were re-evaluated for remaining or residual symptoms. Nasal obstruction, mouth breathing, snoring, hearing loss and nasal discharge were present preoperatively in 55 (91.6%), 51 (85%), 50 (83%), 28 (46%) and 45 (75%), respectively. We found that 53 of 60 children (88.3%) completely recovered from their preoperative symptoms. Of the remaining seven patients, four had persistent nasal obstruction, five mouth breathing, three snoring and two hearing loss. We also noted that the parents of 53 of 60 children were satisfied after the operation. Adenoidectomy provided significant relief and improvement of preoperative presenting symptoms, and it also showed a high rate of parent satisfaction.

KALA-AZAR ASSOCIATED WITH COOMBS-POSITIVE AUTOIMMUNE HEMOLYTIC ANEMIA IN THE PATIENTS COMING FROM THE ENDEMIC AREA OF THIS DISEASE AND SUCCESSFUL TREATMENT OF THESE PATIENTS WITH LIPOSOMAL AMPHOTERICIN B

Kala-azar is an intracellular parasitic infection that infects and multiplies in the macrophages of the liver, the spleen, and the bone marrow. It is characterized by intermittent fever, hepatosplenomegaly, pancytopenia, and hypergammaglobulinemia. Although anemia is a usual finding, Coombs-positive autoimmune hemolytic anemia (AIHA) has rarely been reported with this disease. Pentavalent antimonial compounds remain the mainstay of treatment worldwide. Liposomal amphotericin B (L-AmB) is currently preferred in the treatment of kala-azar because of the resistance to pentavalent antimonals. The authors diagnosed kala-azar associated with Coombs-positive AIHA in 3 patients and treated them with L-AmB (1–5 mg/kg/day) for 30–36 days. Now, all of these patients are healthy following up at the outpatient base for 18–34 months. Kala-azar must be considered in patients with Coombs-positive AIHA and living in and coming from the endemic region for this disease, and it can be successfully treated with L-AmB.

Oral vitamin B12 treatment is effective for children with nutritional vitamin B12 deficiency.

Despite being one of common preventable deficiency disorders, vitamin B12 (vit‐B12) deficiency can lead to serious health problems both in children and adult. The familiar treatment through parenteral route for vit‐B12 deficiency frequently leads to poor adherence, and adequate response to treatment has lead to interest in oral supplementation. This study investigates the efficacy of oral vit‐B12 treatment in children with nutritional vit‐B12 deficiency.

The role of nitric oxide in Doxorubicin-induced cardiotoxicity: experimental study.

Objective: We evaluated the myocardial damage in rats treated with doxorubicin (DOX) alone and in combination with nitric oxide synthase (NOS) inhibitors. Materials and Methods: Twenty-four male Sprague Dawley rats (12 weeks old, weighing 262±18 g) were randomly assigned into 4 groups (n=6). Group I was the control group. In Group II, rats were treated with intraperitoneal (ip) injections of 3 mg/kg DOX once a week for 5 weeks. In Group III, rats received weekly ip injections of 30 mg/kg L-NAME (nonspecific NOS inhibitor) 30 min before DOX injections for 5 weeks. In Group IV, rats received weekly ip injections of 3 mg/kg L-NIL (inducible NOS inhibitor) 30 min before DOX injections for 5 weeks. Rats were weighed 2 times a week. At the end of 6 weeks, hearts were excised and then fixed for light and electron microscopy evaluation and tissue lipid peroxidation (malondialdehyde). Blood samples were also obtained for measuring plasma lipid peroxidation. Results: Weight loss was observed in Group II, Group III, and Group IV. Weight loss was statistically significant in the DOX group. Findings of myocardial damage were significantly higher in animals treated with DOX only than in the control group. Histopathological findings of cardiotoxicity in rats treated with DOX in combination with L-NAME and L-NIL were not significantly different compared with the control group. The level of plasma malondialdehyde in the DOX group (9.3±3.4 µmol/L) was higher than those of all other groups. Conclusion: Our results showed that DOX cardiotoxicity was significantly decreased when DOX was given with NO synthase inhibitors.

The effect of maxillary sinus surgery on its development

Conclusion. The study showed that surgery in the maxillary sinus can affect its development. Objective. To quantitatively evaluate the long-term impact of sinus surgery on its development in the rabbit. Materials and methods. This was an experimental study performed at an academic tertiary medical center using 20 4-week-old New Zealand white rabbits. The rabbits underwent unilateral right maxillary sinus surgery. The contralateral maxillary sinus used as a control did not undergo the operation. The maxillary sinus ostium was enlarged on the operated side. Volumetric analysis of the maxillary sinus was performed 1 year post-surgery. The maxillary sinus volumes of both sides were calculated using Multidedector CT and the volumetric measurements of the operated side were compared with the non-operated side. Results. Maxillary sinus development was significantly reduced on the surgical side. Maxillary sinus growth on the surgical side was determined as 87% compared with the non-surgical side.

In vitro determination of apoptotic effect of heparin on lymphoblasts by using flow cytometric DNA analysis and measurements of caspase-9 activation and cytochrome C level.

Heparin induces apoptosis on peripheral neutrophils, mononuclear cells of the healthy controls, and on lymphoblasts of the patients with acute lymphoblastic leukemia, in vitro. We studied the caspase-9 activity and cytochrome C level as the indicators of the apoptotic effect of heparin on lymphoblasts by the intrinsic pathway of apoptosis. Twenty samples of the patients with acute lymphoblastic leukemia were included in the study. Cytochrome C level and caspase-9 activity were concomitantly determined with the percentage of apoptotic lymphoblasts when incubated in 0, 10, and 20 U/mL heparin concentrations at 0, 1, and 2 hours. The percentages of apoptosis of lymphoblasts at the first hour were higher than those at 0 and 2 hours in 10 and 20 U/mL heparin concentrations, separately (P<0.05). The mean percentage of apoptosis of lymphoblasts in 20 U/mL heparin levels was significantly higher than those in 0 and 10 U/mL heparin levels at 1 and 2 hours (P<0.05). The highest apoptotic effect of heparin on lymphoblasts was determined at the first hour in 20 U/mL heparin concentration. The mean caspase-9 activitity at the first hour was significantly higher than the values at 0 and 2 hours in 10 and 20 U/mL heparin levels, separately (P<0.05). The mean caspase-9 activity in 20 U/mL heparin concentration was significantly higher than values in 0 and 10 U/mL heparin concentrations at 1 and 2 hours (P<0.05). The highest caspase-9 activity was determined in 20 U/mL heparin levels at the first hour. The mean cytochrome C level at the first hour was significantly higher than those at 0 and 2 hours in 10 and 20 U/mL heparin concentrations, separately (P<0.05). The highest cytochrome C level was determined in 20 U/mL heparin concentration at the first hour. We claimed that heparin induces the apoptosis of lymphoblasts by the activation of the intrinsic pathway.

Remission Following Paclitaxel and Cisplatin Treatment in a 15-Year-Old Patient With Unresectable Esophageal Squamous Cell Cancer

To the Editor: We read with great interest the report by Hama et al1 about plasmacytoid dendritic cell leukemia in children. We hereby report our own experience on this extremely rare and aggressive neoplasm. A 4-year-old female was first seen at a rheumatology department because of a 6-month history of migratory polyarthralgia and nonpruriginous papulas on her chest, back, and legs. She had undergone a knee sinovectomy and a course of corticoid therapy with transient clinical. In the course of the investigation, a skin biopsy was performed and it revealed a dermal and subcutaneous neoplasic infiltrate of round cells, CD45+, CD4+, CD56+, CD68+, CD11c+, Cd117+, CD15 , MPX , CD34+, and CD20+, compatible with blastic plasmacytoid dendritic cell neoplasm (BPDCN). Bone marrow (BM) examination showed a pathologic population of 64% with an immunophenotype of dendritic cells and G-banding analysis of BM cells revealed a complex karyotype with del(3)(q12B 13q27), del(7)(p13p21), del(11)(q14q23), 18, 20,+2mar[cp9]/46,XX[8]. Cerebrospinal fluid cytology showed no evidence of involvement by malignant cells. Induction treatment with INTERFANT99 protocol2 was initiated and complete remission (CR) was achieved after induction therapy (both skin lesions and BM involvement). However, on day 30 of induction therapy she developed septic shock with bilateral pneumonia by metapneumovirus and acute respiratory distress syndrome, requiring vasopressor support and invasive ventilation. She developed progressive respiratory failure with bilateral pneumothorax and, despite all the measures, she died in CR. BPDCN is a rare, aggressive tumor, which primarily affects the elderly.3 The overall prognosis in adults is poor, with a reported median overall survival (OS) of 8.7 months.4 Even though there is lack of consensus regarding the optimal treatment approach, acute lymphoblastic leukemia (ALL)/lymphoma-type therapies with CNS prophylaxis and hematopoietic stem cell transplant hematopoietic stem cell transplant (HSCT) in first CR seem to be a justified option.4–6 Childhood BPDCN might represent a different subset of the disease, characterized by a less frequent cutaneous involvement and a better prognosis.7 A review of 25 pediatric BPDCN cases, most of these treated with highrisk-ALL or non-Hodgkin lymphoma protocols, without HSCT, reported an OS of 72% with a median follow-up of 30 months.7 In another analysis of published data, the 3-year OS in 32 published pediatric cases was 57.4%±10.9%.7 Both studies found that skin involvement was associated with worse outcome, prompting Sakashita et al8 to suggest HSCT in first CR following ALL induction regiment for children with BPDCN with cutaneous manifestation. Blastic dendritic neoplasic cells seem to be initially chemosensitive to active agents against lymphoblasts, but their myeloid lineage derivation may suggest that addiction of “myeloid strategies,” such as cytarabine, could be useful to improve outcome. Considering this rationale, the paucity of data, and lack of consensus regarding the optimal treatment approach, we report a treatment option using a protocol initially designed for infants under 1 year with ALL or biphenotypic leukemia.2 Conclusions from published cases in the literature carry several biases and are often more optimistic than real-life experience as poor outcome cases are less often reported. Larger numbers are required and a central registry would be an option to consider.

A Case of All Developing Posterior Reversible Encephalopathy Secondary to Hyponatremia.

Posterior reversible encephalopathy syndrome (PRES), may be due to different causes. It may develop secondary to hypertension, renal decompensation, electrolyte imbalance, and chemotherapeutic drugs. We describe a case of acute lymphoblastic leukemia in which PRES developed secondary to hyponatremia despite being normotensive during receipt of chemotherapy. Magnetic resonance imaging findings were suggestive of PRES. Partial diffusion restriction was observed in lesions in the bilateral occipitoparietal regions and the cerebellum. The patient was treated with appropriate medications with the resolution of his stroke-like symptoms. No neurological deficit was observed and clinical condition improved. The patient continued with chemotherapy. Early diagnosis and treatment of this syndrome is important in terms of preventing neurological sequelae. Cases of secondary PRES developing for several etiological reasons have been reported in induction therapy, but no pediatric cases of PRES developing secondary to hyponatremia despite being normotensive while receiving chemotherapy in acute lymphoblastic leukemia have previously been reported.

Pulmonary Findings Of H1N1 Infection In Children With Malign Disease

Introduction: H1N1 influenza virus may be fatal due to immunosuppression in malignant diseases and chronic diseases. Patients frequently present with influenza-like symptoms, high fever, and diarrhea, and the clinical course may be aggressive, possibly ending in respiratory failure. The purpose of this study was to examine the radiological findings of patients who were diagnosed with cancer and had H1N1 infection. Material and Method: Ten cases with a positive H1N1 PCR among 94 patients who were followed-up with a diagnosis of cancer at the hematology and oncology clinic between January 2010 and January 2016 were included in the study. Cases were divided into two groups according to the absolute neutrophil count, having a neutrophil count ≥500 /μL in Group A (five patients) and neutrophil count <500 μL in Group B (five patients). Chest x-ray and thoracic computed tomography of the patients were evaluated. Results: Eight of ten patients received active chemotherapy. Chest x-rays of all patients were initially within normal ranges. Bilateral pulmonary infiltration was observed in the findings of chest x-ray in six patients (60%), one in Group A and five in Group B. The most frequently involvement was at the lower zones of the lungs. The most obvious chest x-ray finding was a patch-shaped consolidation. Seven out of ten patients (70%), two in group A and five in group B, had a ground glass appearance and consolidation in thoracic computed tomography. A total of four cases (40%) died due to respiratory failure, one in group A and three with severe neutropenia in group B. Discussion: Early chest x-ray findings might frequently be normal in patients who have H1N1 influenza virus infection at the moment, although they have clinical signs. Radiological findings become more significant with the advancement of the clinical picture. Therefore, H1N1 influenza virus infection should be considered when