Chihiro Kawakami

Assessment of Corticosteroid-induced Osteonecrosis in Children Undergoing Chemotherapy for Acute Lymphoblastic Leukemia: A Report From the Japanese Childhood Cancer and Leukemia Study Group

Steroid-induced osteonecrosis (ON) is a challenging complication encountered during modern chemotherapy for childhood acute lymphoblastic leukemia (ALL). We retrospectively assessed the incidence of ON and its risk factors in a total of 1095 patients enrolled in 3 consecutive Japanese Children’s Cancer and Leukemia Study Group ALL studies (ALL941 [1994 to 2000], n=464; ALL2000 [2000 to 2004], n=305; and ALL2004 [2004 to 2010], n=326). ON was diagnosed in 16 patients, of whom 15 were symptomatic. The cumulative incidence of ON was 0.76% in ALL941, 0.35% in ALL2000, and 3.6% in ALL2004. The incidence of ON in ALL941/2000, in which only prednisolone was administered as a steroid, was significantly lower than that in ALL2004, in which dexamethasone was used as a partial substitute for prednisolone (P<0.01). In ALL2004, sex and age were significantly correlated with the incidence of ON (1.3% in boys vs. 6.7% in girls, P=0.0132; 0.42% for age <10 y vs. 15.6% for age ≥10 y, P<0.0001), suggesting that girls aged 10 years and above are at a greater risk of ON onset. These results indicate that the risk of ON should be considered when administering dexamethasone as part of ALL protocol treatment in girls aged 10 years and above.

Induction of Apoptosis by γ-Tocotrienol in Human Cancer Cell Lines and Leukemic Blasts From Patients: Dependency on Bid, Cytochrome c, and Caspase Pathway

Tocotrienols (Toc3) have been suggested to possess anticancer effects besides antioxidant and antiinflammatory effects. Previous studies have demonstrated that Toc3 induce apoptosis in epithelial carcinoma. However, the effects of Toc3 on malignant hematopoietic cells have not yet been thoroughly investigated. We investigated Toc3-induced apoptosis in human hematological cancer cell lines. α-, δ-, and γ-Toc3 induced concentration-dependent apoptosis, and γ-Toc3 demonstrated more effective induction than the other Toc3 derivatives in HL-60 cells. γ-Toc3 may have induced apoptosis by activation of the caspase cascade, cytochrome c (Cyt.c) release, Bid cleavage, and mitochondorial membrane depolarization in HL-60, NB-4, Raji, and SY-5Y cells. Furthermore, 10–30 μM γ-Toc3 showed cytotoxicity for leukemic cells from various patients regardless of lymphoblastic, myeloblastic, or relapsed leukemia, but the cytotoxic effect was weak in normal mononuclear cells, interestingly. γ-Toc3 may have a role in cancer prevention and potential for treating hematological malignancies.

Plasma All-Trans Retinoic Acid Level in Neonates of Mothers with Acute Promyelocytic Leukemia

We have encountered 3 cases of APL in pregnancy as shown in table 1 . All 3 mothers were diagnosed as having APL in the third trimester. They received standard oral induction therapy with ATRA (45 mg/m 2 divided into 2 doses) for 2–4 weeks. Chemotherapy was performed after cesarean section. All of them achieved complete remission after this additional chemotherapy. None of the mothers suffered any toxicity during ATRA therapy. All the neonates were delivered safely, but had the complications shown in table 1 . All of them required intubation for respiratory distress syndrome (RDS). Their complications improved with appropriate treatment. Case 2 was reported previously because this neonate had premature atrial contraction [5] . Laboratory data were within the normal range and none of the neonates had dermatitis, dry skin, or cheilitis, which are known toxicities of ATRA. We measured the plasma ATRA level in umbilical cord blood, as well as in the mothers and neonates ( fi g. 1 A). The method of measuring ATRA levels has been described previously [8] . ATRA was detected in the maternal plasma of case 2, and in the maternal and neonatal plasma of case 3. Transfer of ATRA to the fetus occurred as shown in fi gure 1 B. 9cis RA and 13cis RA, which are Alltrans retinoic acid (ATRA) therapy for acute promyelocytic leukemia (APL) achieves a high complete remission rate with mild side effects during induction therapy. APL is characterized by the chromosomal translocation (15; 17), which results in fusion of the PML gene and the retinoic acid receptor (RAR) gene. Recently, this translocation has been related to oncogenesis in APL, and identifi cation of the molecular mechanism of oncogenesis is underway. The administration of chemotherapy during the fi rst trimester is associated with a high rate of fetal malformation [1] . However, it has been reported that pregnant women with APL can be treated by ATRA and control of disseminated intravascular coagulation during the second and third trimesters allowing safe delivery of the fetus with no serious complications [2–6] . Although vitamin A and its derivatives are known to be teratogenic in early pregnancy, little is known about its effects in late pregnancy [7] . In this study, we measured plasma ATRA levels in the umbilical cord blood of neonates born to mothers treated with ATRA during pregnancy. These neonates were followed up after delivery. Received: August 26, 2004 Accepted after revision: February 8, 2005

Azacitidine in the treatment of pediatric therapy-related myelodysplastic syndrome after allogeneic hematopoietic stem cell transplantation.

We herein present a case of pediatric therapy-related myelodysplastic syndrome (t-MDS) with complex karyotype who was treated with azacitidine (AZA) for AML1-EVI1 fusion transcript as minimal residual disease after allogeneic hematopoietic stem cell transplantation (HSCT). The patient was started on AZA 41 days after the HSCT without having achieved complete remission. After 9 cycles of AZA, the AML1-EVI1 fusion transcript disappeared, and there was no manifestation of graft versus host disease during AZA treatment. Preemptive AZA treatment for minimal residual disease has an acceptable safety profile and appears to be an effective strategy for preventing or substantially delaying hematological relapse in pediatric patients with high-risk myelodysplastic syndrome after HSCT.

Kawasaki Disease in a Patient with Wiskott-Aldrich Syndrome: An Increase in the Platelet Count

Figure 1. The clinical course of the patient with Kawasaki Disease. PLT indicates platelet; IVIG, intravenous immunoglobulin; CRP, C-reactive protein; Day, the clinical day after the patient exhibited fever during the course of Kawasaki Disease. We report a unique case of Wiskott-Aldrich syndrome (WAS) associated with Kawasaki Disease (KD). A male Japanese patient had eczema, purpura, and recurrent infections beginning in early infancy and was found to have thrombocytopenia (platelet count, 20-50 109/L). The platelet size was also small (mean platelet volume, 4.0-5.0 fL). The patient was medicated with immunoglobulin and oral prednisolone to increase the platelet count, but counts remained low. The patient developed KD at the age of 6 months (high fever over 5 days, systemic rash, swelling of fingers and toes, conjunctival swelling, strawberrylike tongue, and cervical lymphadenopathy were seen), and the blood platelet count increased transiently in the acute phase (Figure 1) and decreased immediately after administration of high doses of immunoglobulin (1 g/kg 2 days) for the prophylaxis of coronary aneurysm. He was medicated with immunoglobulin (0.5 g/kg 3 days) again to increase platelets after he was cured of KD, but the platelets did not increase. WAS was diagnosed because results of analysis of the WAS protein (WASP) gene showed a missense mutation (in intron 6, 597G→A) and Western blot analysis results showed less progression of WASP than occurs in healthy controls. Although there are a few reports of WAS with vasculitis syndromes (ie, Takayasu arteritis [1] and HenochSchonlein purpura [2]), no report to our knowledge has ever described the combination of WAS and KD. There are some reports that interleukin-6, one of the inflammatory cytokines, is increased in KD patients [3]. Interleukin-6 has been reported to be a potent thrombopoietic Kawasaki Disease in a Patient with Wiskott-Aldrich Syndrome: An Increase in the Platelet Count

A case of congenital bone marrow failure with radio-ulnar synostosis

Bone marrow failure is often associated with skeletal defects, as seen in Fanconi anemia [1], Diamond-Blackfan anemia [2], or thrombocytopenia-absent radius syndrome [3]. Congenital amegakaryocytic thrombocytopenia with radio-ulnar synostosis has been reported to be related with HOXA11 mutation [4]. We present a boy with congenital bone marrow failure with radio-ulnar synostosis, but without HOXA11 mutation. A boy, born to non-consanguineous parents, was delivered via Cesarean section at 31 weeks’ gestation for hydrops fetalis resulting from severe anemia. He had severe anemia (hemoglobin 2.7 g/dl), severe neutropenia (white blood cells 3,220/ll with 1.5% neutrophils), and moderate thrombocytopenia (platelets 89,000/ll) at birth. Neutrophils continued to be nearly absent and platelet counts progressively decreased below 20,000/ll by 2 weeks of age. He had no hepatosplenomegaly, lymphadenopathy, or cafe-au-lait spot, but had hydrocele testicle, sensorineural hearing loss, and overlapping fingers without abnormalities of bone. Supination of his bilateral forearms was restricted and X-rays revealed bilateral proximal radio-ulnar synostosis (Fig. 1). Bone marrow aspiration showed aplasia without dysplasia. Chromosomal analysis revealed a 46, XY, inv(9)(p12q13) karyotype, which is considered to be normal variant without physiologic role. He lacked a family history of hematological or skeletal disorders. No excessive chromosomal breakage was detected by mitomycin C stimulation, and no mutation was found for the Shwachman–Bodian–Diamond syndrome (SBDS) gene. He had repeated bacterial and viral infections after birth, requiring antibiotics and prophylactic antifungal agents. He also needed repeated transfusions of red blood cells and platelets until 8 months of age when he underwent a 5/6 human leukocyte antigen (HLA)-matched unrelated bone marrow transplantation (BMT). Pretransplant conditioning was with fludarabine, cyclophosphamide, and thoracicabdominal irradiation (2 Gy). Prophylaxis for graft-versushost disease (GVHD) was short-term methotrexate and tacrolimus. Engraftment was prompt and grade 1 acute cutaneous GVHD was observed. By 20? days following BMT, he became independent of all transfusions. He has had normal hematological studies for 14 months after BMT. Limb formation is regulated by HOX genes during embryonic development. The most 50 members of the HOXA and HOXD clusters (HOXA9–HOXA13 and HOXD9–HOXD13) are particularly important in limb development [5]. HOX genes are also well known to be associated with hematopoiesis and leukemogenesis [6]. The effects of Hoxa10 and Hoxd11 were found to be on forearm development from studies of mutant mice [7, 8]. Radio-ulnar synostosis with congenital thrombocytopenia has been reported to be associated with HOXA11 mutation [4], which prompted us to examine HOX genes. However, we detected no mutations of HOXA11 and HOXD11. Of the three patients with radio-ulnar synostosis and thrombocytopenia reported by Thompson et al. [9], one H. Yoshida Y. Hashii T. Okuda S. Kusuki E. Sato H. Ohta (&) K. Ozono Department of Pediatrics, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita 565-0871, Japan e-mail: ohta@ped.med.osaka-u.ac.jp

Severe bone marrow failure associated with human parvovirus B19 infection in a case with no underlying disorder

Human parvovirus B19 (B19) is known to induce erythema infectiosum. B19 mainly attacks the erythroid progenitor cells of the bone marrow and arrests their proliferation [1], but generally these alterations improve spontaneously within a short period. We report a previously healthy boy with persistent severe bone marrow aplasia associated with B19 infection. A 14-year-old boy complaining of fever and purpura was referred to our hospital. He had been healthy with no history of hemolytic disorders and no recent episodes of medication use. The pyrexia had commenced 3 days prior to the referral, and purpura appeared in his legs and arms 2 days before. The white blood cell (WBC) count was low (1.84 9 10/L; neutrophils 0.47 9 10/L); this was accompanied with reticulocytopenia (9.2 9 10/L) and thrombocytopenia (12.0 9 10/L). A bone marrow examination performed on day 1 of hospitalization revealed marked hypoplasia (nuclear cell count 4.0 9 10/L, Fig. 1a) complicated with neither dysplasia nor hemophagocytosis. Chromosomal analysis showed normal 46XY type. Serum B19 IgM by enzyme immunoassay (EIA) was positive, and the B19 DNA copies in his serum were amplified over the cut-off point (5 9 10 copies/L) by polymerase chain reaction (PCR). Serum EB virus VCA-IgM and cytomegalovirus IgM by EIA were negative. Neutrophils and platelets accumulated within 10 days of hospitalization without any treatment. However, these cell counts reduced slightly on and after 20 weeks. After further observation without treatment, the WBC remained low (2.85 9 10/L; neutrophils 1.11 9 10/L) with mild reticulocytopenia (36.5 9 10/L) and thrombocytopenia (53.0 9 10/L) at 30 weeks. Neither blood B19 DNA nor serum B19 IgM was detected. A second bone marrow examination performed at 30 weeks showed that the hypoplasia (nuclear cell count 7.5 9 10/L, Fig. 1b) remained. An experimental human study [1] has shown that B19 induces the maturation arrest of erythroid precursor cells for 1 week. Furthermore, an in vitro study [2] has reported that B19 does not affect the activity of hematopoietic stem cells. However, some reports have found that (1) B19 particles are observable in both erythroid and granulocytic precursors on electromicroscopy [3], (2) B19 DNA are detected in leukocytes of infected patients [4], and (3) B19 inhibits colony proliferation of megakaryocyte precursors [5]. It has generally been recognized that B19 induces pure red cell aplasia in cases in which erythrocyte life span is shorter, such as hereditary spherocytosis [6], and causes severe bone marrow failure in cases involving immunodeficiency, such as the maintenance phase of acute leukemia [7]. On the other hand, there have been reports of severe cytopenia following B19 infection in some older children [8–10] or adults [11] absent underlying disease. In the present case, the aplasia remained even after both B19 DNA and B19 IgM were negative. Although it is difficult to exclude the possibility that this case was complicated with other hematological disorders, such as pre-leukemic leukemia or myelodysplastic syndrome; two bone marrow examinations found no dysplasia in his erythroid or myeloid progenitor cells. His persistent bone marrow aplasia suggests that the B19 seronegative and genomic negative C. Kawakami (&) Y. Kono A. Inoue K. Takitani H. Tamai Department of Pediatrics, Osaka Medical College Hospital, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan e-mail: ped076@poh.osaka-med.ac.jp

X-linked agammaglobulinemia complicated with endobronchial tuberculosis

Aim:  We report a case of X‐linked agammaglobulinemia complicated with endobronchial tuberculosis.

Three brothers of X-linked agammaglobulinemia: the relation between phenotype and neutropenia

X-linked agammaglobulinemia (XLA, i.e. Bruton’s agammaglobulinemia [1]) is an X chromosomal recessive primary immunodeficiency syndrome, which is caused by insufficiency of antibody production. In 1993, BTK (Bruton’s tyrosine kinase) gene, the critical gene of XLA, was discovered in Xq22 by Tsukada et al. [2] and Vetrie et al. [3]. We report a family case with XLA, and describe the difference of clinical outcome between the proband and his brothers.

Successful treatment of acute monocytic leukemia with intracranial hemorrhage as the first manifestation

A 14-year-old girl complaining of severe headache was brought to our emergency room in an ambulance. Her medical history was not remarkable, except for an almost-closed ventricular septal defect. The headache commenced approximately 24 h before she was brought to the emergency room and worsened in the final few hours before treatment. She was slightly disoriented and could not converse fluently (Glasgow Coma Scale score, 13 points). Muscle power was evidently decreased in the right extremities, and pyramidal signs (Barre sign and Babinski sign) in the right extremities were positive. Computed tomography (CT) of the brain revealed two hematomas in the subcortical brain: one measured approximately 5 cm ¥ 3 cm and was located in the left temporoparietal area (Fig. 1a), and the other measured approximately 0.5 cm ¥ 0.5 cm and was located in the right parietal lobe. The white blood cell count was considerably high (128.5 ¥ 10/L; monoblasts, 92%; neutrophils, 4%); this was accompanied by anemia (hemoglobin level, 57 g/L) and thrombocytopenia (platelet count, 14.0 ¥ 10/L). The blood prothrombin time was prolonged (55%; international normalized ratio, 1.33); however, the levels of plasma fibrinogen and fibrinogen degradation products were within the normal limits. The patient had never had an episode of bleeding due to coagulopathies, and her plasma protein C and antithrombin III levels were normal. Because she had been definitely diagnosed with acute leukemia, we started an infusion of solutions and transfused donated blood containing red blood cells, platelets, and plasma particles immediately after hospitalization, even before analyzing the bone marrow cells. Bone marrow examination was, however, performed on day 3 of hospitalization, and it revealed abnormal blasts (80% of nuclear cells were monoblasts, which is a characteristic of the M5 subtype of acute myeloid leukemia [AML] with CD13, CD33, CD34, CD117, CD11c, and human leukocyte antigen-(HLA)-DR antigens. Chromosomal analysis of the blasts performed using G-banding revealed normal 46XY type chromosomes. We did not observe any AML-associated representative mRNA rearrangements. The volume of ICH, as determined by magnetic resonance (MR) imaging of the brain (Fig. 1b), increased with the passage of time, that is, from day 1 to day 2. The two ICH lesions were simple hematomas that were not surrounded by low-intensity areas. MR angiography did not indicate the presence of any vascular disorders such as arteriovenous malformations, hemangiomas, or Moyamoya disease. On day 3, the hematomas appeared smaller than on day 2. After conservative treatment with nafamostat mesilate, glycerol, and edaravone, the ICH was controlled (Fig. 2) on day 7. We then commenced remission induction chemotherapy involving the intravenous administration of etoposide, cytarabine, and mitoxantrone with intrathecal injections (Fig. 2) without any premedical treatment such as cranial irradiation or leukapheresis. Thereafter, the white blood cell count dramatically decreased, and the blasts disappeared from the peripheral blood within 15 days of chemotherapy. Except for blood toxicity (grade IV in the Common Terminology Criteria for Adverse Events (CTCAE) version 3.0), we did not observe any adverse events, including acute renal injury, which can occur due to rapid lysis of the blasts. Brain CT findings were normal, and neurological deficits were alleviated by day 50 of hospitalization. The bone marrow blasts persisted (20%) even after the completion of two courses of induction chemotherapy (the second course included etoposide, idarubicin, and high-dose cytarabine). Therefore, we administered salvage chemotherapy comprising fludarabine, cytarabine, and a granulocyte colonystimulating factor (FLAG-IDA). This FLAG-IDA regimen enabled complete remission, although critical adverse events such as neutropenia (with grade IV blood toxicity and grade III Enterococcus infection in CTCAE version 3.0) were observed. After craniospinal irradiation with 12 Gy of radiation, which was administered as a supplemental treatment to eradicate the remnant leukemic cells from the brain and spine, allo-peripheral blood stem cell transplantation was performed; the patient’s Correspondence: Chihiro Kawakami, MD, Department of Pediatrics, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki, Osaka 569-8686, Japan. Email: ped076@poh.osaka-med.ac.jp Received 30 April 2009; revised 31 January 2010; accepted 1 March 2010. Pediatrics International (2010) 52, e218–e220 doi: 10.1111/j.1442-200X.2010.03138.x