István Szegedi

Comparison of PFA-100 Closure Time and Template Bleeding Time of Patients with Inherited Disorders Causing Defective Platelet Function

MINI REPORT Comparison of PFA-100 Closure Time and Template Bleeding Time of Patients with Inherited Disorders Causing Defective Platelet Function Adrienne Kerenyi1, Agota Schlammadinger2, Eva Ajzner1, Istvan Szegedi3, Csongor Kiss3, Zoltan Pap4, Zoltan Boda2 and Laszlo Muszbek1 1Department of Clinical Biochemistry and Molecular Pathology, 2Second Department of Medicine, 3Department of Pediatrics, University Medical School of Debrecen, Debrecen, 4City Health Service, Ophthalmology Unit, Debrecen, Hungary.

Significance of oral Candida infections in children with cancer

Candidiasis is common in children with cancer, particularly during periods of severe immunosuppression and neutropenia. Our aim was to study the microbiological changes in the oral cavity of children with newly diagnosed cancer. The study group consisted of 30 consecutive children and adolescents, 16 with acute lymphoblastic leukemia and 14 with solid tumors. Oral cultures to detect fungi and bacteria were conducted for all patients before treatment, during and after neutropenic episodes. In 23 patients developing fever simultaneous throat, urine and blood sampling was carried out. No pathogens were found in the cultures taken before the outset (30 cultures) or after recovery from (30 cultures) the neutropenic episodes. In the 45 oral cultures taken during the neutropenic episodes 38 (84.4%) proved positive. Fungi were the most frequently isolated oral pathogens: 33/38 yeast and 6/38 bacterial infections were identified. There was no association between the underlying malignancy and the occurrence of the positive cultures. Of the 30 patients, all 23 (76.7%) who have developed moderate-to-severe neutropenia, developed oral fungal colonization or clinically obvious fungal infection at least on one occasion during the study. In addition to oral samples, fungi were identified in 9/23 pharyngeal swabs, 6/23 urine and 1/23 blood cultures. The initial fungal pathogen was exclusively (33/33)Candida albicans. In extended severe neutropenic states,C. albicans was replaced by non-albicans species (C. kefyr, C. lusitaniae, C. sake, C. tropicalis) in 5 patients between 4 to 6 days of the neutropenic episodes. Four of the nonalbicansCandida strains were resistant to azole-type antifungal agents. Neutropenic episodes of children with cancer are associated with an increased risk of developing oral and even systemic infections withC. albicans that can be replaced by azole-resistant nonalbicans strains in prolonged neutropenia contributing to morbidity of these patients.

Effect of myelopoietic and pleiotropic cytokines on colony formation by blast cells of children with acute lymphoblastic leukemia

Abstract. The aim of this study was to see whether pleiotropic or myeloid hematopoietic growth factors, which do not stimulate normal lymphoid cells, can induce proliferation of blast cells of the acute lymphoid leukemia (ALL) of childhood. Bone marrow cells of 13 children with untreated ALL (nine common ALL, two myeloid antigen positive ALL and two early T-cell ALL) formed colonies of leukemic blast cells in primary methylcellulose cultures. Spontaneous growth was observed in three of 13 cases, whereas phytohemagglutinin-stimulated leukocyte conditioned medium (PHA-LCM), a conventional source of various natural human cytokines, induced colony formation in ten of 13 cases. A similar rate of responsiveness was seen with recombinant human granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF) and stem cell factor (SCF); a combination of these three cytokines induced colony formation in all cases studied. The effect of these growth factors on colony formation seemed to be dose-dependent in some cases. Of the stimuli studied, GM-CSF induced the smallest number of colonies, whereas the effects of G-CSF, SCF and PHA-LCM were similar in this respect. Combination of cytokines proved to be even more efficient in inducing clonal proliferation of leukemic lymphoblasts. In double combinations, G-CSF and GM-CSF as well as G-CSF and SCF were able to potentiate each others effects. Triple combination of these cytokines mediated the most potent growth stimulus.Our results demonstrate that myeloid and pleiotropic cytokines are able to stimulate clonal proliferation of pediatric leukemic lymphoblasts. This may present a potential hazard to children with ALL while on adjuvant therapy with hematopoietic growth factors. In vitro colony assays performed prior to or in parallel with the administration of hematopoietic growth factors to ALL patients may help to forecast their possible effects on leukemic cells in vivo.

Complete recovery from psychosis upon miglustat treatment in a juvenile Niemann–Pick C patient

Niemann-Pick disease type C is a rare lipid trafficking disorder characterized by the accumulation of cholesterol and glycosphingolipids in the brain and viscera. Perinatal, early infantile, late infantile, juvenile and adult forms are distinguished based on the age of manifestation. In the juvenile form, patients in their early years are usually, but not always, symptom free, but present with neurodegeneration later in their lives. These include clumsiness, ataxia, seizures, motor and intellectual decline. Psychiatric manifestations may occur at any stage of the disease. These manifestations include schizophrenia, presenile dementia, depression or psychosis. In 2009, miglustat was approved for the therapy of the disease. We present a case of a patient with juvenile Niemann-Pick C disease whose psychosis was reversed completely by miglustat treatment. Based on our clinical experience we suggest considering Niemann-Pick C in cases of therapy-resistant psychosis and encourage the introduction of miglustat in Niemann-Pick C patients even in the most advanced cases, with respect to psychiatric illness.

Combined local treatment and chemotherapy in the management of bilateral retinoblastomas in Hungary

This retrospective study supports that brachytherapy combined with cytostatic therapy may effectively contribute to tumor control. The second eye of 13 patients with bilateral retinoblastoma was treated with plaque brachytherapy after the enucleation of the first eye. Eleven patients received systemic cytostatic therapy. The mean follow up was 60 (±42 SD) months. Twelve patients are alive and free of tumor, 8 of them with acceptable visual acuity. After cytostatic therapy, late nephropathy was observed in 2 patients. In conclusion, brachytherapy combined with cytostatic therapy will be an option in the management of bilateral retinoblastoma after the enucleation of the first eye.

Altered expression of autophagy‐related genes might contribute to glucocorticoid resistance in precursor B‐cell type acute lymphoblastic leukemia

Autophagy is an evolutionarily conserved process playing an important role in tumor cells resistance to chemotherapy. Response to glucocorticoid (GC) treatment is out of the most important prognostic factors in childhood acute lymphoblastic leukemia (ALL); however, only few data are available connecting GC response and role of autophagy. Our aim was to investigate whether altered expression of autophagy‐related genes contributes to GC‐resistant phenotype in GC‐sensitive and GC‐resistant precursor B‐cell‐type (PBC) ALL cells.

Early relapse after rituximab chemoimmunotherapy

In relapsed/refractory childhood acute lymphoblastic leukemia (ALL) of the B‐cell lineage rituximab, a monoclonal anti‐CD20 antibody was used successfully in some cases. We report on a 15‐year‐old female with relapsed CD20‐positive B‐cell progenitor ALL treated with rituximab because of positive minimal residual disease signals after chemotherapy, as checked by flow cytometry and real time quantitative‐PCR. Rituximab eliminated the CD20‐positive subpopulation, but not the more immature leukemic cells. The patient died with fulminant aspergillosis before hematopoietic stem cell transplantation could be performed. Pediatr Blood Cancer 2008;50:372–375.

Slow response of invasive Candida krusei infection to amphotericin B in a clinical time-kill study

For many decades, amphotericin B (AMB) has been the treatment of choice for severe invasive candidiasis. However, recent studies have indicated that MIC90 values of AMB against many Candida species are high, especially against C. krusei (MIC90=8 mg/l) [1]. In recognition of this trend, an AMB dose of at least 1 mg/kg/day is currently recommended for the treatment of invasive C. krusei infections [2]. Reported here is a case of recurrent candidemia with hepatosplenic involvement caused by C. krusei in a 3-yearold girl with acute lymphoblastic leukemia (ALL). This uncommon pediatric pathogen was eradicated following multiple courses of amphotericin B deoxycholate (AMB-d) and amphotericin B lipid complex (ABLC) administered for 81 and 44 days in total, respectively. The patient was admitted to the Pediatric Hematology Unit of the University of Debrecen on 28 February 2001 and was diagnosed with ALL on the same day (day 0). Induction therapy with prednisolone, vincristine, daunorubicin and L-asparaginase was initiated. The first neutropenic period started on day 5 and lasted for 23 days (neutrophil count, 0.1–0.4×10/l). The patient became febrile (body temperature, ≥38.5°C) on day 8, and empiric antibiotic therapy with ceftazidime plus metronidazole was consequently started. On day 12, therapy was switched to amikacin plus ceftazidime plus AMB-d. The AMB-d dose was gradually increased from 0.3 to 1 mg/kg/day during the course of 1 week. Blood samples obtained on days 12 and 16 yielded C. krusei, as did a urine sample taken on day 12 (10 cfu/ml). Although blood and urine cultures became negative, septic shock developed on day 26 (pulse rate, 143/min; blood pressure, 75/41 mmHg), and the patient was transferred to the intensive care unit (platelet count, 8× 10/l; C-reactive protein level, CRP, 423 mg/l). Induction chemotherapy was interrupted and granulocyte colony stimulating factor (5 μg/kg/day for 5 consecutive days) and massive platelet replacement were administered. On day 33 the ALL was determined to be in remission. During the patient’s stay in intensive care, multiple subcutaneous abscesses developed throughout the body. On days 33, 40 and 41, C. krusei was cultured from samples taken from dermal abscesses on the patient’s right hand, chest and scalp. On day 42 AMB-d was switched to ABLC (5 mg/kg/day for 15 days). Further subcutaneous abscess samples were negative from day 46 onwards, and yeasts were no longer cultured until resolution (day 125). Abdominal ultrasound performed weekly after recovery from neutropenia showed focal hypoechogenic lesions (5–12 mm in diameter) characteristic of hepatosplenic candidiasis in the liver, spleen and kidneys. Liver enzyme levels were elevated (lactate dehydrogenase, 721 U/l; alkaline phosphatase, 1090 U/l; γ-glutamyl transferase, 920 U/l). From day 66 to day 112 AMB-d was readministered (1 mg/kg/day, 35 times), but switched to ABLC (5 mg/kg/day for 14 days) again on day 170. At the end of this course, fever resolved. Post-consolidation therapy (dexamethasone, vincristine, daunorubicin, and L-asparaginase) was started on day 189. During subsequent neutropenic periods (days 203–214 and days 227–237, respectively) fever recurred (body temperature over 38.5°C, Eur J Clin Microbiol Infect Dis (2006) 25:803–806 DOI 10.1007/s10096-006-0200-5

Potential Biological Markers of Atrial Fibrillation: A Chance to Prevent Cryptogenic Stroke

Stroke affects millions of people all over the world, causing death and disability. The most frequent type of this disease is ischemic stroke, which can be caused by different factors. In approximately 25 percent of cases, no obvious cause can be found. Recent observations have shown that paroxysmal atrial fibrillation could be responsible for a significant number of cryptogenic stroke events. Short- or long-lasting ECG monitoring could help with the diagnosis of transient arrhythmias. Unfortunately, these techniques either are expensive or require good patient compliance. An alternative option is the identification of biological markers that are specific for atrial fibrillation and can be used to predict arrhythmia. In this review, we give a summary of the recent advances in the research of arrhythmia markers. Based on their structure and function, we differentiated four groups of biomarkers: markers of inflammation, markers of fibrosis, markers with hormonal activity, and other markers. In spite of intensive researches, the optimal biological marker is still not available, but there are some promising markers, like NT-proBNP/BNP.

In vitro and in vivo activity of 4-thio-uridylate against JY cells, a model for human acute lymphoid leukemia.

We have previously reported the in vitro anti-proliferative effect of 4-thio-uridylate (s(4)UMP) on OCM-1 uveal melanoma cells. Here, we assessed the efficacy of s(4)UMP on JY cells. Treatment of JY cells with s(4)UMP suppressed their colony forming activity and induced apoptosis; healthy human bone marrow granulocyte-macrophage progenitor cells were 14-fold less sensitive to the nucleotide. In vivo effectiveness of s(4)UMP was determined using xenograft SCID mouse model. s(4)UMP decreased the cell number and colony forming activity of the total cell content of the femur of SCID mice transplanted with JY cells without affecting the bone marrow of healthy mice. These results suggest that s(4)UMP alone or in combination with other clinically approved anti-leukemic remedies should be further explored as a potential novel therapeutic agent.